|
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
|
