Privacy Practice NoticePinehurst, NC
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 carefully. If you have any questions about this Notice please contact the Privacy Officer.
Telephone: 910-685-7395; Fax: 910-692-7977: Email: [email protected]
Effective Date: April 14, 2003, Revised: April 13, 2013
We are committed to protect the privacy of your personal health information (PHI).
This Notice of Privacy Practices (Notice) describes how we may use within our practice or network and disclose (share outside of our practice or network) your PHI to carry out treatment, payment or health care operations. We may also
share your information for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your PHI. We are required by law to maintain the privacy of your PHI. We will follow
the terms outlined in this Notice. We may change our Notice, at any time. Any changes will apply to all PHI. Upon your request, we will provide you with any revised Notice by:
Uses and Disclosures of Protected Health Information
We may use or disclose (share) your PHI to provide health care treatment for you. Your PHI may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. EXAMPLE: Your PHI may be provided to a physician to whom you have been referred for evaluation to ensure that the physician has the necessary information to diagnose or treat you. We may also share your PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. We may also share your PHI with people outside of our practice that may provide medical care for you such as home health agencies. We may use and disclose your PHI to obtain payment for services. We may provide your PHI to others in order to bill or collect payment for services. There may be services for which we share information with your health plan to determine if the service will be paid for. PHI may be shared with the following:
Your Privacy Rights
You have certain rights related to your protected health information. All requests to exercise your rights must be made in writing. [Describe how the patient may obtain the written request document and to whom the request should be directed, i.e. practice manager, privacy officer.] You have the right to see and obtain a copy of your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. If requested we will provide you a copy of your records in an electronic format. There are some exceptions to records which may be copied and the request may be denied. We may charge you a reasonable cost-based fee for a copy of the records. You have the right to request a restriction of your protected health information. You may request for this practice not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. We are not required to agree with requests. If we agree to a restriction request we will honor the restriction request unless the information is needed to provide emergency treatment. There is one exception: we must accept a restriction request to restrict disclosure of information to a health plan if you pay out of pocket in full for a service or product unless it is otherwise required by law. You have the right to request for us to communicate in different ways or in different locations. We will agree to reasonable requests. We may also request alternative address or other methods of contact such as mailing information to a post office box. We will not ask for an explanation from you about the request. You may have the right to request an amendment of your health information. You may request an amendment of your health information if you feel that the information is not correct along with an explanation of the reason for the request. In certain cases, we may deny your request for an amendment at which time you will have an opportunity to disagree. You may have the right to a list of people or organizations who have received your health information from us. This right applies to disclosures for purposes other than treatment, payment or health care operations. You have the right to obtain a listing of these disclosures that occurred after April 14, 2003. You may request them for the previo·us six years or a shorter timeframe. If you request more than one list within a 12 month period you may be charged a reasonable fee. Additional Privacy Rights
If you think we have violated your rights or you have a complaint about our privacy practices you can contact: Privacy Officer Phone: 910-685-7395, Fax 910-692-7977 or Email: [email protected] You may also complain to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us. If you file a complaint we will not retaliate against you for filing a complaint. This notice was published and becomes effective on April 13, 2013.
Click here to print a copy of our Privacy Practice Notice
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