This Notice describes how health
information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
The
privacy of your health information Is important to us.
This Notice describes how we may use and disclose
your protected health information to provide treatment, obtain payment and
conduct health care operations and for other purposes
permitted or required by law. It also describes your rights concerning your protected health
information. “Protected health information” is information about you,
including demographic information that may
identify you and relates to your past, present or future physical or
mental health or condition and related
health care services.
We are required by law to
follow the practices described in this Notice. We may change the terms of this Notice at any time. The
new Notice will effective for all protected health information we maintain at
that time including health information we created or received before we made
the changes.
You may obtain a copy of our Notice of Privacy
Practices at any time by calling our office
or requesting one at your next appointment
Treatment- We will use
and-disclose your health information to provide, coordinate and
manage health care and related services for
you. For example we will disclose information to a specialist to whom
you have been referred to ensure the provider
has enough information to diagnose and/or treat you. We may also disclose information to a laboratory
that, at our request, becomes involved in your treatment.
Payment: We may use and disclose
your information to obtain payment
for services we provided to you. For example we will send
the necessary information to your health or dental insurance company to obtain
payment for the treatment provided.
These activities include, but
are not limited to, quality assessment
and improvement activities, review of the performance and qualifications of employees, evaluating practitioner
and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
We may use a sign-in sheet at the
registration desk where you will
be asked to sign your name. We may also call you by name
in the waiting room when we are ready to begin your treatment. We may send
postcard appointment reminders. We may leave appointment reminders messages on
your answering machine.
We will share your protected health information with
business associates that perform specific
functions for our practice such as
billing, When a business arrangement of this type requires the use of your information, we will have
a written contract with the third
party to protect the privacy of your protected health information.
Others Involved In Your Health
Care:
We must disclose your health information to you as described in the
Patient Rights section of this Notice. We may disclose your
health information to a family member or other person to the extent necessary to help with your health care or with
payment for your health care, but only if you agree. If we determine it
is in your best interest based on our professional judgement or experience with common practices, we may allow
another person to pick up filled
prescriptions, medical supplies, x-rays or other forms of health
information.
We may use or disclose protected
health information to notify or
assist in notifying a family member, a personal representative
or any other person responsible for your care of your location, your general condition or death. If you are present
prior to the use or disclosure of your protected health information, we will
provide you with the opportunity to object to
such uses or disclosures. Finally, we may use or disclose your protected
health information to an authorized public or private entity to assist in
disaster relief efforts and to coordinate uses and disclosures to family
members or others involved in your health care.
Emergencies:
In the event of your incapacity or in emergency
circumstances, we may use or disclose your protected health information to
treat you.
Uses and Disclosures of Protected Health Information Based upon Your 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, except to
the extent that an action has already been taken in reliance on the
authorization.
Other Permitted and Required Uses and Disclosures -That May Be Made Without
Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health
information in the following situations without your consent or authorization.
These situations include:
Required By Law:
We may use or disclose
your protected health information to the
extent that law requires the use or disclosure. The use or disclosure will be made
in compliance with the law and will be limited to the relevant requirements of
the law.
We must make disclosures to you and, when required,
to the Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of the Privacy Rule, Section
164.500 et seq.
Public Health:
We may disclose your protected
health information for public health
activities and purposes to a public health
authority that is permitted by law to collect or receive the information. The disclosure will be made for the
purpose of controlling disease, injury or disability.
Additionally, we may disclose your protected
health information, if authorized by law,
to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or
spreading the disease or condition.
We may disclose protected health information to a
health oversight agency for activities
authorized by law, such as audits, investigations, and
inspections. Oversight agencies include
government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect:
We may disclose your protected health information to
a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may
disclose your protected health information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to
receive such information. In this case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
Legal Proceedings:
We may disclose protected health information in the
course of any judicial or administrative proceeding,
in response to an order of a court or administrative tribunal (to the extent such disclosure is
expressly authorized in certain
conditions in response to a subpoena, discovery request or
other lawful process.
Law Enforcement:
We
may also disclose protected health information,
so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement
purposes include (1) legal processes and otherwise required by law, (2) limited information requests for
identification and location purposes, (3) pertaining to victims of a crime, (4)
suspicion that death has occurred’ as
a result of criminal conduct, (5) in
the event. a crime occurs on the premises of the practice, and (6)
medical emergency (not on the Practice’s premises) and it is likely that a
crime has occurred.
Military Activity and National Security:
When the appropriate conditions
apply, we may disclose, to military authorities,
protected health information of individuals
who are Armed Forces personnel. We may also disclose your
protected health information to authorized
federal officials for conducting
national security and intelligence activities including for the provision of protective services to the President
or others legally authorized
Workers’ Compensation:
we may disclose your protected health
information as authorized to comply with workers’ compensation laws and other similar legally established programs.
Inmates:
We may use or disclose your
protected health information
if you are an inmate of a correctional facility and your physician created or received your’ protected health information
in the course of providing care to you.
Your rights with respect to your protected health
information and how you may exercise those rights are outlined below.
You have a right to obtain a copy and/or inspect your
health information; Health information
includes treatment records, billing records and any other records used by us to
make decision about your treatment- You may obtain a form from our office to
request access. A reasonable cost-based fee will be charged for expenses such
as staff time, copies and postage. Contact us as indicated at the end of this
Notice to obtain information about our fees or if you have any questions about
your access.
You
have a right to request a restriction on the use and disclosure of your protected health information:
You may ask us not to use or disclose some part of your protected
health information for the purposes of
treatment, payment or operations. You
may also request that we not disclose some part of your information to family and others who may be involved
in your care or for notification purposes as otherwise described in this
Notice. We are not required to agree to the restrictions but if we do, we are obligated to
abide by the agreement except in cases of emergency. You may request a restriction by sending
your request in writing to our Privacy Contact.
You have a right to request to receive confidential communications 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. Please make this
request in writing to our Privacy Contact‑
You may have the right to request
an amendment to your protected
health Information.
You may request that we amend protected health information about you. Your
request must be in writing with an explanation as
to why the information should be amended. In
certain cases, we may deny your
request for an amendment. If we deny your request. for amendment, you
have the right to file a statement of disagreement
with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain
disclosures we have made, if any, of your
protected health information.
This right applies to disclosures made by our Business
Associates or us. It excludes disclosures for treatment, payment or healthcare
operations as described in this Notice of Privacy Practices, to you,
to family members or friends involved in your care, for notification
purposes or as a result of an authorization signed by you_ You have the
right to receive specific information regarding these disclosures
that occurred after April 14, 2003 for up to the previous 6 years. You
may request a shorter timeframe. Ile right to receive this information
is subject to certain exceptions, restrictions and limitations.
If you request an accounting more than once in a 12 month period, we will
charge you a reasonable cost-based fee for responding to the additional request.
You have the right to obtain a paper copy of this notice from
us, upon request, even if you have agreed to accept this notice electronically.
QUESTIONS AND COMPLAINTS:
If you have any questions,
concerns or want more information about our privacy practices please contact us
using the information below.
If you are concerned that we
may have violated your privacy rights or you disagree with a decision we have
made regarding your access to your health information or any other request you
have made in the exercise of your rights, you may send your complaint to us
usi9njg the information below. You may
also submit a written complaint to the Secretary of Health and Human
Services. Contact us for the address of
the Department of Health and Human Services.
We support your right to the
privacy of your health information and we will not retaliate against you in any
way for filing a complaint.
CONTACT OUR OFFICE:
Phone: 704-825-9991
Fax: 704-825-7966
Address:
5803 Wilkinson Blvd.
Belmont, NC 28012
This notice was published
and becomes effective on April 14, 2003