NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
This Notice describes privacy practices of this practice, including: any health care professional authorized to enter information into your health/medical
records; any volunteer group we allow to help while you are receiving care.
I. Our Duty to Safeguard Your Protected Health Information:
Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for your
health care is considered “Protected Health Information” (“PHI”). We understand that medical information about you and your health is personal and we are
committed to protecting medical information about you. We are required by law to make sure that your PHI is kept private and to give you this Notice about
our legal duties and privacy practices, that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or
disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.
We must follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at
any time. If we change this Notice, we will post a new Notice in patient registration and/or patient reception. The Notice will contain the effective date
on the first page, top right-hand corner. You may request a copy of the new Notice from the staff (and it will also be posted on our website at ). We will
also make available a copy of the Notice in effect each time you visit.
II. How We May Use and Disclose Your Protected Health Information:
We use and disclose PHI for a variety of reasons. For certain uses/disclosures, we must get your written authorization. However, the law provides that we
may make some uses/disclosures without your authorization. The following section offers more description and examples of our potential uses/disclosures of
- Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Generally, we may use/disclose your PHI:
- For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For
example, your PHI will be shared among members of your treatment team, pharmacy staff, or with a specialist to whom you have been referred. We may also
share PHI with health care provider licensing bodies like the North Carolina State Department of Health.
- To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may release
portions of your PHI to Medicare/Medicaid, a private insurer or group health plan to get paid for services that we delivered to you. Release of your PHI to
the state Medicaid agency might also be necessary to determine your eligibility for publicly funded services.
- For health care operations: We may use/disclose your PHI in the course of our operations. For example, we may use your PHI or your answers to a
patient satisfaction survey in evaluating the quality of services provided by our staff, or disclose your PHI to our auditors or attorneys for audit or
- Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to
your home. We may also call your home and leave a message on your answering machine or voicemail. (See Section III about confidential communication.)
- Treatment Alternatives: We may contact you about possible treatment options or alternatives, or other health-related benefits or services that
may interest you.
- Fundraising: We may contact you to raise money for operations, unless you tell us in writing not to contact you for this purpose.
- Uses and Disclosures Requiring Authorization: For uses and disclosures other than treatment, payment and operations purposes, we are required to
have your written authorization, unless the use or disclosure falls within one of the exceptions described below. You may revoke an authorization, in
writing, any time to stop future uses/disclosures. If you revoke your authorization, we will stop using/disclosing your PHI for purposes or reasons covered
by your written authorization. You need to understand that we are unable to take back disclosures we have already made with your permission and that we are
required to keep our records of the care we provided to you. (See Section VI for instructions for revoking an authorization.) We cannot refuse to treat you
if you refuse to sign an authorization to release PHI, unless services provided are solely to create health records for a third party, such as a physical
and drug testing for an employer or insurance company; or if treatment provided is research-related and authorization is required for the use of health
information for research purposes.
- Uses and Disclosures Not Requiring Authorization: The law provides that we may use/disclose your PHI without your authorization in the following
- When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or
relating to suspected criminal activity, for FDA-regulated products or activities, or in response to a court order. We must also disclose PHI to
authorities that monitor compliance with these privacy requirements.
- For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital
statistics to the public health authority, such as reports of tuberculosis cases or births and deaths.
- For health oversight activities: We may disclose PHI to the Indiana State Department of Health or other agencies responsible for monitoring the
health care system for such purposes as reporting or investigation of unusual incidents.
- Relating to decedents: We may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ
procurement organizations relating to organ, eye, or tissue donations or transplants.
- For research purposes: In certain circumstances, that have been approved by an Institutional Review Board, we may disclose PHI in order to
assist medical research, such as comparing the health and recovery of all patients who received one medicine to those who received another. We will almost
always ask you for your specific permission if the researcher will have access to your name, address and other PHI, or will be involved in your case.
- To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement
officials in circumstances such as: in response to a court order; to identify a suspect, witness or missing person; about crime victims; about a death that
we may suspect if the result of criminal conduct; or criminal conduct at the health care facility.
- For specific government functions: We may disclose PHI of military personnel and veterans in certain situations; to correctional facilities in
certain situations; and for national security and intelligence reasons, such as protection of the President.
- Workers’ Compensation: We may disclose your PHI to your employer for Workers’ Compensation or similar programs that provide benefits for
work-related illness or injury.
- Inmates: An inmate does not have rights listed in this Notice of Privacy Practices. The rights listed in this notice will not apply to inmates
of a correctional institution.
III. Your Rights Regarding Your Protected Health Information:
- Uses and Disclosures Requiring You to Have an Opportunity to Object: In the following situations, we may disclose your PHI if we inform you
about the disclosure in advance and you have the opportunity to agree to or prohibit or restrict the disclosure. However, if there is an emergency
situation and you cannot be given the opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and the disclosure
is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.
- To families, friends or others involved in your care: We may share with these people information directly related to your family’s, friend’s or
other person’s involvement in your care or payment for your care. We may also share PHI with these people to notify them about your location, general
condition or death.
- Disaster relief: We may release your PHI to a public or private relief agency for purposes of coordinating notifying your family and friends of
your location, condition or death in the event of a disaster.
You have the following rights relating to your protected health information:
IV. How to Complain about our Privacy Practices:
- To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. You must make your request
in writing. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our
use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. If agreed upon, these restrictions will
only apply to this health care facility. You understand that we are not able to take back disclosures already made. We cannot agree to limit
uses/disclosures that are required by law.
- To request confidential communication: You have the right to ask that we send you information at an alternative address or by an alternative
means, such as contacting you only at work. You must make your request in writing. We must agree to your request as long as it is reasonably easy for us to
- To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your
protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you
written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed. You
have a right to choose what portions of your information you want copied and to have information on the cost of copying in advance.
- To request amendment to your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in
writing, that we correct or add to the record. Written requests must include a reason that supports your request. We will respond within 60 days of
receiving your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also
deny your request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to
be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial reviewed, along with any statement in
response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that
need to know about the change in the PHI. Any laboratory records subject to the Clinical Laboratory Act of 1988 (CLIA) are exceptions to this rule.
- To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has
been released other than instances of disclosure for which you gave your written authorization. (This is called an accounting of disclosures.) Your request
can relate to disclosures going as far back as six (6) years. This list will not include any disclosures made before April 14, 2003, for national security
purposes, for treatment, payment or operations purposes, or to law enforcement officials or correctional facilities. Your request must be in writing. We
will respond to your written request for such a list within 60 days of receiving it. There will be no charge for the first list requested each year. There
may be a charge for subsequent requests.
- To receive a paper copy of this Notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request.
To obtain a copy of this Notice, contact this facility's Privacy Contact.
If you think we may have violated your privacy rights, or if you disagree with a decision we made about access to your PHI, you may file a complaint with
the facility’s Privacy Contact. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. You will not
be penalized if you file a complaint.
V. Contact Person for Information or to Submit a Complaint:
If you have questions about this notice or any complaints about our privacy practices, please contact this facility’s Privacy Contact.
VI. Instructions for Revoking an Authorization:
You may revoke an authorization to use or disclose your PHI, in writing, except: 1) to the extent that action has been taken in reliance on the
authorization, or 2) if the authorization was obtained as a condition of obtaining insurance coverage and law provides the insurer with the right to
contest a claim under the policy. Your written revocation must include the date of the authorization, the name of the person or organization authorized to
receive the PHI, your signature and the date you signed the revocation.
VII. Effective Date:
This Notice was effective 4/17/07.