We
must provide this Notice to each patient beginning no later than the
date of our first service delivery to the patient, including service
delivered electronically, after April 14, 2003. We must make a good-faith
attempt to obtain written acknowledgement of receipt of the
Notice from the patient. We must also have the Notice available
at the office for patients to request to take with them.
We must post the Notice in our office in a clear and prominent
location where it is reasonable to expect any patients seeking
service from us to be able to read the Notice. Whenever
the Notice is revised, we must make the Notice available upon request
on or after the effective date of the revision in a manner
consistent with the above instructions. Thereafter,
we must distribute the Notice to each new patient at the time of service
delivery and to any person requesting a Notice. We must also post the
revised Notice in our office as discussed above.
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.
OUR
LEGAL DUTY
We
are required by applicable federal and state law to maintain the privacy
of your health information. We are also required to give you this Notice
about our privacy practices, our legal duties, and your rights concerning your
health information. We must
follow the privacy practices that are described in this Notice while
it is in effect. This Notice
takes effect 04-15-03 and
will remain in effect until we replace it. We
reserve the right to change our privacy practices and the terms of this
Notice at any time, provided such changes are permitted by applicable
law. We reserve the right
to make the changes in our privacy practices and the new terms of our
Notice effective for all health information that we maintain, including
health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change
this Notice and make the new Notice available upon request.
You
may request a copy of our Notice at any time. For more information about
our privacy practices, or for additional copies of this Notice, please contact
us using the information listed at the end of this Notice
USES AND DISCLOSURES OF
HEALTH INFORMATION
We
use and disclose health information about you for treatment, payment,
and healthcare operations.
For
example:
Treatment:
We may use or disclose your health information to a physician or
other healthcare provider providing treatment to you.
Payment:
We may use and disclose your health information to obtain payment
for services we provide to you.
Healthcare
Operations:
We may use and disclose your health information in connection
with our healthcare operations. Healthcare
operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or credentialing
activities.
Your Authorization:
In addition
to our use of your health information for treatment, payment or
healthcare operations, you may give us written authorization to use your
health information or to disclose it to anyone for any purpose. If you
give us an authorization, you may revoke it in writing at any time. Your
revocation will not affect any use or disclosures permitted by your authorization
while it was in effect. Unless
you give us a written authorization, we cannot use or disclose your
health information for any reason except those described in this Notice.
To Your Family and Friends:
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, friend or other
person to the extent necessary to help with your healthcare or with
payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care:
We may use or
disclose health information to notify, or assist in the notification
of (including identifying or locating) a family member, your personal
representative or another person responsible for your care, of your
location, your general condition, or death. If you are present, then
prior to use or disclosure of your health information, we will provide you
with an opportunity to object to such uses or disclosures. In
the event of your incapacity or emergency circumstances, we will
disclose health information based on a determination using our
professional judgment disclosing only health information that is
directly relevant to the person's involvement in your healthcare.
We will also use our professional judgment and our experience with
common practice to make reasonable inferences of your best interest
in allowing a person to pick up filled prescriptions, medical supplies,
x-rays, or other similar forms of health information.
Marketing Health-Related
Services:
We
will not use your health information for marketing communications
without your written authorization.
Required by Law:
We may use or
disclose your health information when we are required to do so by law.
Abuse or Neglect:
We may disclose your health information to
appropriate authorities if we reasonably believe that you are a possible
victim of abuse, neglect, or domestic violence or the possible victim
of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health
or safety of others.
National Security:
We may disclose to military authorities the health
information of Armed Forces personnel under certain circumstances.
We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence, and
other national security activities. We may disclose to correctional institution
or law enforcement official having lawful custody of protected health
information of inmate or patient under certain circumstances.
Appointment Reminders:
We may use or disclose your health information to provide you
with appointment reminders (such as voicemail messages, postcards, or
letters).
Access:
You have the right to look at or get copies of your health
information, with limited exceptions. You may request that we provide
copies in a format other than photocopies. We will use
the format you request unless we cannot practicably do so. (You must
make a request in writing to obtain access to your health information.
You may obtain a form to request access by using the contact information
listed at the end of this Notice. We
will charge you a reasonable cost-based fee for expenses such as copies
and staff time. You may
also request access by sending us a letter to the address at the end
of this Notice. If you request copies, we will charge you $1.00 for each
page, and postage if you want the copies mailed to you. If you request
an alternative format, we will charge a cost-based fee for providing
your health information in that format. If you prefer, we will prepare
a summary or an explanation of your health information for a fee. Contact
us using the information listed at the end of this Notice for a full
explanation of our fee structure.
Disclosure Accounting:
You have the
right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than
treatment, payment, healthcare operations and certain other activities,
for the last 6 years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests.
Restrictions:
You have the
right to request that we place additional restrictions on our use or
disclosure of your health information. We are not required to agree to
these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency).
Alternative Communication:
You have the
right to request that we communicate with you about your health
information by alternative means or to alternative locations. (You must
make your request in writing.) Your request must specify the alternative
means or location, and provide satisfactory explanation how payments
will be handled under the alternative means or location you request.
Amendment:
You have the
right to request that we amend your health information. (Your request
must be in writing, and it must explain why the information should be
amended.) We may deny your request under certain circumstances.
Electronic
Notice:
If
you receive this Notice on our Web site or by electronic mail (e-mail),
you are entitled to receive this Notice in written form.
Questions and Complaints:
If you want more information about our privacy practices or have
questions or concerns, please contact us.
If
you are concerned that we may have violated your privacy rights,
or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict
the use or disclosure of your health information or to have us communicate
with you by alternative means or at alternative locations, you may
complain to us using the contact information listed at the end of
this Notice. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with
the address to file your complaint with the U.S. Department of Health
and Human Services upon request. We support your right to the privacy
of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of
Health and Human Services.
Contact Officer:
North Carolina DHHS/HIPAA
Office
Telephone: (919) 855-3171
Fax: (919) 733-8871
E-mail: DHHS.HIPAA.Questions@ncmail.net
Mailing
Address:
HIPAA
Office,
2015 Mail Service Center,
Raleigh, NC 27699-2015
Physical Address: HIPAA
Office,
695 Palmer Drive, Raleigh, NC 27603-2250
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