Compliance and HIPAA

Arundel Lodge Compliance Program

The purpose of a compliance program is to deter, detect, and prevent fraud, abuse, and mistakes. Corporate Compliance is a system of effective internal controls that promote adherence to federal and state law; program requirements of federal, state, and private health plans; and ethical behavior.

As a part of Arundel Lodge’s Compliance Program, we provide an anonymous reporting hotline. The purpose of this service is to ensure that anyone wishing to submit a report anonymously has the ability to do so. Reports may cover the following topics; fraud, conflict of interest, violation of the law, quality of service, violation of company policy, discrimination, ethical violations, theft, or internal controls.

The following toll free numbers and other methods of reporting are available 24 hours a day, 7 days a week.

  1. Phone:English: (855) 400-6002

    Spanish: (800) 216-1288

  2. Website:
  3. Email: [email protected] (must include company name with report )
  4. Fax: (215) 689-3885 (must include company name with report)

Your Rights to Confidentiality

Arundel Lodge takes confidentiality very seriously. We follow very strict rules from the United States and Maryland Governments about when we can release your medical record—your protected health information.

The Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes a foundation of Federal protection for personal health information, carefully balanced to avoid creating unnecessary barriers to the delivery of quality health care. The Rule generally prohibits this program from using or disclosing your protected health information unless authorized by you, except as follows:

First, we are required by law to disclose your protected health information in certain circumstances, for example, to report abuse and neglect, and to warn about dangerous behavior. Second, we are authorized to disclose your protected health information without your consent when we use that information for treatment, payment, or the health care operations of the program.

You can also request a copy of our notice at any time. For more information about our privacy practices, contact our human resources office.

Human Resources
Arundel Lodge, Inc.
2600 Solomons Island Road
Edgewater, MD 21037
443-433-5900, ext. 5931


If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. 

If you have any questions or complaints, please contact:

Human Resources
Arundel Lodge, Inc.
2600 Solomons Island Road
Edgewater, MD 21037
443-433-5900, ext. 5931

Uses and Disclosures of Protected Health Information

The following are examples of the types of uses and disclosures of your protected health care information that the provider is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures.

Treatment:  We will use and disclose health information to provide, coordinate, or manage your health care and any related services. For example, your protected health information may be provided to a doctor to whom you have been referred to insure that the doctor has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, in activities related to obtaining payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to your health insurance company to obtain approval for the hospital admission.

Healthcare Operations:  We may use or disclose, as needed, your protected health information as it relates to business activities. For example, when we review employee performance, we may need to look at what an employee has documented in your medical record.

Business Associates:  We will share your protected health information with third party ‘business associates’ that perform various activities (e.g. billing, transcription services). Whenever an arrangement between us and a business service involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Marketing:  We may use or disclose certain health information in the course of providing you with information about treatment alternatives, health-related services, or fundraising. You may contact us to request that these materials not be sent to you.

Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing.

Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to object. If you are not present or able to object, then your provider may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories:  Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name.  Members of the clergy will be told your religious affiliation.

Others Involved in Your Healthcare:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.

Emergencies:  In an emergency treatment situation, your provider shall try to provide you a Notice of Privacy Practices as soon as reasonably practicable after the delivery of treatment.

Communication Barriers:  We may use and disclose your protected health information if your provider attempts to obtain acknowledgement from you of the Notice of Privacy Practices but is unable to do so due to substantial communication barriers and the provider determines, using professional judgment that you would agree.

Without Opportunity to Object

We may use or disclose your protected health information in the following situations without your authorization or opportunity to object:

Public Health:  for public health purposes to a public health authority or to a person who is at risk of contracting or spreading your disease.

Health Oversight:  to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

Abuse or Neglect:  to an appropriate authority to report child abuse or neglect, if we believe that you have been a victim of abuse, neglect, or domestic violence.

Food and Drug Administration: as required by the Food and Drug Administration to track products.

Legal Proceedings:  in the course of legal proceedings.

Law Enforcement:  for law enforcement purposes, such as pertaining to victims of a crime or to prevent a crime.

Coroners, Funeral Directors, and Organ Donation:  for the coroner, medical examiner, or funeral director to perform duties authorized by law and for organ donation purposes.

Research:  to researchers when their research has been approved by an Institutional Review Board.

Soldiers, Inmates, and National Security:  to military supervisors of Armed Forces personnel or to custodians of inmates, as necessary.  Preserving national security may also necessitate sharing protected health information.

Workers’ Compensation:  to comply with workers’ compensation laws.

Compliance:  to the Department of Health and Human Services to investigate our compliance.

In general, we may use or disclose your protected health information as required by law and limited to the relevant requirements of the law.

Your Rights

You have the right to:

Inspect and copy your protected health information.  However, we may refuse to provide access to certain psychotherapy notes or information for a civil or criminal proceeding.

Request a restriction of your protected health information.  You may ask us not to use or disclose certain parts of your protected health information for treatment, payment or healthcare operations.  You may also request that information not be disclosed to family members or

friends who may be involved in your care.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  We are not required to agree to a restriction that you may request, but if we do agree, then we must behave accordingly.

Request to receive confidential communications from us by alternative means or at an alternative location.  We will accommodate reasonable requests.  We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request.

Ask your provider to amend your protected health information.  You may request an amendment of protected health information about you.  If we deny your request for an amendment, you have the right to file a statement of disagreement with us, and your medical record will note the disputed information.

Receive an accounting of certain disclosures we may have made.  This right applies to disclosures for purposes other than treatment, payment, or healthcare operations.  It excludes disclosures we may have made for you, for a facility directory, to family members or friends involved in your care, or for notification purposes.  You have the right to receive specific information regarding these disclosures.  The right to receive this information is subject to certain exceptions, restrictions, and limitations.

Obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Updated August 2016. Printed from HIPAA in 24 Hours, and Overview of HIPAA Privacy Standards manuals with permission from the authors Roy Rada, M.D., Ph.D., & Susan Sugar Nathan.

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online here, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

2. Fax:
(833) 256-1665 or (202) 690-7442; or

3. Email:
[email protected]

This institution is an equal opportunity provider.