As required by the Privacy Regulations Created as a Result of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE,
PLEASE CONTACT
The Clinical Manager at 336-621-3777.
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A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your PHI
- Your privacy rights in your PHI
- Our obligations concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE
CONTACT: The Clinical Manager at 336-621-3777.
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your PHI.
- Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment
- Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.
- Health Care Operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.
- Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
- Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
- Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
- Release of Information to Family/Friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you.
- Disclosures Required By Law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN
SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we
may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may
disclose your PHI to public health authorities that are authorized
by law to collect information for the purpose of:
- maintaining vital records, such as births and deaths
- reporting child abuse or neglect
- preventing or controlling disease, injury or disability
- notifying a person regarding potential exposure to a communicable
disease
- notifying a person regarding a potential risk for spreading
or contracting a disease or condition
- reporting reactions to drugs or problems with products or devices
- notifying individuals if a product or device they may be using
has been recalled
- notifying appropriate government agency(ies) and authority(ies)
regarding the potential abuse or neglect of an adult patient (including
domestic violence); however, we will only disclose this information
if the patient agrees or we are required or authorized by law
to disclose this information
- notifying your employer under limited circumstances related
primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose
your PHI to a health oversight agency for activities authorized
by law. Oversight activities can include, for example, investigations,
inspections, audits, surveys, licensure and disciplinary actions;
civil, administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government programs,
compliance with civil rights laws and the health care system in
general.
3. Lawsuits and Similar Proceedings. Our practice may use
and disclose your PHI in response to a court or administrative order,
if you are involved in a lawsuit or similar proceeding. We also
may disclose your PHI in response to a discovery request, subpoena,
or other lawful process by another party involved in the dispute,
but only if we have made an effort to inform you of the request
or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release PHI if asked to do so
by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable
to obtain the person’s agreement
- Concerning a death we believe has resulted from criminal conduct
- Regarding criminal conduct at our offices
- In response to a warrant, summons, court order, subpoena or
similar legal process
- To identify/locate a suspect, material witness, fugitive or
missing person
- In an emergency, to report a crime (including the location
or victim(s) of the crime, or the description, identity or location
of the perpetrator)
5. Deceased Patients. Our practice may release PHI to a
medical examiner or coroner to identify a deceased individual or
to identify the cause of death. If necessary, we also may release
information in order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your
PHI to organizations that handle organ, eye or tissue procurement
or transplantation, including organ donation banks, as necessary
to facilitate organ or tissue donation and transplantation if you
are an organ donor.
7. Research. Our practice may use and disclose your PHI
for research purposes in certain limited
circumstances. We will obtain your written authorization to use
your PHI for research purposes except when an Institutional Review
Board or Privacy Board has determined that the waiver of your authorization
satisfies the following: (i) the use or disclosure involves no more
than a minimal risk to your privacy based on the following: (A)
an adequate plan to protect the identifiers from improper use and
disclosure; (B) an adequate plan to destroy the identifiers at the
earliest opportunity consistent with the research (unless there
is a health or research justification for retaining the identifiers
or such retention is otherwise required by law); and (C) adequate
written assurances that the PHI will not be re-used or disclosed
to any other person or entity (except as required by law) for authorized
oversight of the research study, or for other research for which
the use or disclosure would otherwise be permitted; (ii) the research
could not practicably be conducted without the waiver; and (iii)
the research could not practicably be conducted without access to
and use of the PHI.
8. Serious Threats to Health or Safety. Our practice may
use and disclose your PHI when necessary to reduce or prevent a
serious threat to your health and safety or the health and safety
of another individual or the public. Under these circumstances,
we will only make disclosures to a person or organization able to
help prevent the threat.
9. Military. Our practice may disclose your PHI if you
are a member of U.S. or foreign military forces
(including veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your PHI
to federal officials for intelligence and national security activities
authorized by law. We also may disclose your PHI to federal officials
in order to protect the President, other officials or foreign heads
of state, or to conduct investigations.
11. Inmates. Our practice may disclose your PHI to correctional
institutions or law enforcement officials if you are an inmate or
under the custody of a law enforcement official. Disclosure for
these purposes would be necessary: (a) for the institution to provide
health care services to you, (b) for the safety and security of
the institution, and/or (c) to protect your health and safety or
the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release
your PHI for workers’ compensation and similar programs.
North Carolina Law. In the event that North Carolina
Law requires us to give more protection to your health information
than stated in this notice or required by Federal Law, we will
give that additional protection to your health information.
E. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about
you:
1. Confidential Communications. You have
the right to request that our practice communicate with you about
your health and related issues in a particular manner or at a certain
location. For instance, you may ask that we contact you at home,
rather than work. In order to request a type of confidential communication,
you must make a written request to our clinical manager specifying
the requested method of contact, or the location where you wish
to be contacted. Our practice will accommodate reasonable requests.
You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request
a restriction in our use or disclosure of your PHI for treatment,
payment or health care operations. Additionally, you have the right
to request that we restrict our disclosure of your PHI to only certain
individuals involved in your care or the payment for your care,
such as family members and friends. We are not required to agree
to your request; however, if we do agree, we are bound by our
agreement except when otherwise required by law, in emergencies,
or when the information is necessary to treat you. In order to request
a restriction in our use or disclosure of your PHI, you must make
your request in writing to our clinical manager. Your request
must describe in a clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use,
disclosure or both; and
(c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect
and obtain a copy of the PHI that may be used to make decisions
about you, including patient medical records and billing records,
but not including psychotherapy notes. You must submit your request
in writing to our clinical manager in order to inspect and/or obtain
a copy of your PHI. Our practice may charge a fee for the costs
of copying, mailing, labor and supplies associated with your request.
Our practice may deny your request to inspect and/or copy in certain
limited circumstances; however, you may request a review of our
denial. Another licensed health care professional chosen by us will
conduct reviews.
4. Amendment. You may ask us to amend your health information
if you believe it is incorrect or incomplete, and you may request
an amendment for as long as the information is kept by or for our
practice. To request an amendment, your request must be made in
writing and submitted to our clinical manager. You must provide
us with a reason that supports your request for amendment. Our practice
will deny your request if you fail to submit your request (and the
reason supporting your request) in writing. Also, we may deny your
request if you ask us to amend information that is in our opinion:
(a) accurate and complete; (b) not part of the PHI kept by or for
the practice; (c) not part of the PHI which you would be permitted
to inspect and copy; or (d) not created by our practice, unless
the individual or entity that created the information is not available
to amend the information.
5. Accounting of Disclosures. All of our patients have the
right to request an “accounting of disclosures.” An
“accounting of disclosures” is a list of certain non-routine
disclosures our practice has made of your PHI for nontreatment,
non-payment or non-operations purposes. Use of your PHI as part
of the routine patient care in our practice is not required to be
documented. For example, the doctor sharing information with the
nurse; or the billing department using your information to file
your insurance claim. In order to obtain an accounting of disclosures,
you must submit your request in writing to our clinical manager.
All requests for an “accounting of disclosures” must
state a time period, which may not be longer than six (6) years
from the date of disclosure and may not include dates before April
14, 2003. The first list you request within a 12-month period is
free of charge, but our practice may charge you for additional lists
within the same 12-month period. Our practice will
notify you of the costs involved with additional requests, and you
may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled
to receive a paper copy of our notice of privacy practices. You
may ask us to give you a copy of this notice at any time. To obtain
a paper copy of this notice, contact our clinical manager.
7. Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with our practice
or with the Secretary of the Department of Health and Human Services.
To file a complaint with our practice, contact our clinical manager.
All complaints must be submitted in writing. You will not be
penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures.
Our practice will obtain your written authorization for uses and
disclosures that are not identified by this notice or permitted
by applicable law. Any authorization you provide to us regarding
the use and disclosure of your PHI may be revoked at any time in
writing. After you revoke your authorization, we will no longer
use or disclose your PHI for the reasons described in the authorization.
Please note, we are required to retain records of your care.
Again, if you have any questions regarding this
notice or our health information privacy policies, please contact
our clinical manager at 336-621-3337.
For information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
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