Notice of Privacy Practices
Effective Date:
April 14, 2003
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!
Our
Responsibilities
We are required by law to protect the privacy of
health information about you that we create and obtain in providing our services
to you. This information is called “protected health information,” or “PHI” for
short. This PHI may include documentation of your symptoms, examination and
test results, diagnoses, treatment, and applications for future care or
treatment. PHI also includes billing documents for the services you receive.
We are required to give you notice of our legal duties and privacy practices
concerning PHI:
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We must maintain
the privacy of your PHI as required by law;
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We must provide you with this Notice
explaining our legal duties and privacy practices as to the PHI we collect and
maintain about you; and
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We must abide by the terms of the
Notice that is currently in effect.
This Notice describes the types of uses and
disclosures that we may make with your PHI and gives you some examples. We will
post this Notice in our offices and, to the extent that we maintain a
comprehensive website, on such website. We reserve the right to amend, change,
or eliminate provisions in our Notice of Privacy Practices and to make the new
provisions effective for all PHI that we maintain. If our information practices
change, we will amend our Notice and post the amended Notice in our offices and,
as applicable, on our website. You are entitled to receive a revised copy of
the Notice by calling and requesting a copy of our “Notice” or by visiting our
office and picking up a copy.
Permitted Uses and Disclosures of PHI
We are permitted by federal privacy laws
to make certain uses and disclosures of your PHI.
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We may use
and disclose your PHI to provide health care treatment to you.
We may use and disclose PHI about you to provide, coordinate or manage your
health care and related services. This may include communicating with other
health care providers regarding your treatment and coordinating and managing
your health care with others. We also may contact you to provide you with
appointment reminders, information about treatment alternatives, or with
information about other health-related benefits and services that may be of
interest to you.
Examples of uses of your PHI for treatment purposes:
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A nurse obtains treatment information about you
and records it in a health record.
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During the course of your treatment, the
physician determines he/she will need to consult with another specialist in
the area. He/she will share the information with such specialist and obtain
his/her input.
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We may use
and disclose your PHI to obtain payment for services.
We may use and disclose PHI about you to
others to bill and collect payment for the treatment and services provided to
you by us or another provider.
Example of use of your PHI for payment purposes:
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We may use
and disclose your PHI for health care
operations.
We may use and disclose PHI in performing
business activities, or “health care operations.” These “health care
operations” allow us to improve the quality of care we provide and reduce
health care costs.
Example of use of your PHI for health care operations:
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We obtain services from our insurers or other
business associates such as quality assessment, quality improvement, outcome
evaluation, protocol and clinical guidelines development, training programs,
credentialing, medical review, legal services, and insurance. We will share
information about you with such insurers or other business associates as
necessary to obtain these services.
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Other Permitted Uses and Disclosures.
We may use and disclose PHI about you in a number of circumstances in
which you do not have to consent or give authorization, though in some
situations you will have an opportunity to object. These circumstances
include:
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Required by law.
We may use or disclose PHI to the extent that
such use or disclosure is required by law and the use or disclosure is
limited to the relevant requirements of such law.
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Public health activities.
As required by law, we may disclose your PHI to
public health or legal authorities charged with preventing or controlling
disease, injury or disability.
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Abuse and neglect.
We may
disclose your PHI to public authorities as allowed by law to report abuse or
neglect.
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Food and Drug Administration (FDA).
We may disclose your PHI to a representative
of the FDA for purposes of activities related to the quality, safety or
effectiveness of FDA-regulated products or activities – for example,
reporting adverse events or enabling product recalls.
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Funeral directors or coroners.
We may disclose your PHI to funeral directors or
coroners, as consistent with applicable law, to allow them to carry out
their duties.
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Organ procurement organizations.
Consistent
with applicable law, we may disclose your PHI to organ procurement
organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
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Health oversight activities.
We may disclose your PHI to appropriate health
oversight agencies for oversight activities authorized by law.
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Judicial and administrative proceedings.
We may disclose PHI in the course of
any judicial or administrative proceeding as allowed or required by law,
with your consent, or subject to a court order.
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Law enforcement.
We may disclose your PHI to a law enforcement
official for law enforcement purposes as permitted or required by law – for
example, when required by a court order, or when an individual is in the
custody of law enforcement.
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Research.
We may disclose PHI to researchers when their
research has been approved by an institutional review board that has
reviewed the research proposal and established protocols to ensure the
privacy of your PHI.
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Serious threat to health or safety.
We may disclose your PHI, in accordance with
applicable law, in order to prevent or lessen a serious, imminent threat to
the health or safety of a person or the public.
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Specialized government functions.
We may disclose your PHI for specialized
government functions as authorized by law – for example, for the conduct of
national security and intelligence activities.
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Workers' compensation.
We may disclose
your PHI to the extent necessary to comply with laws relating to workers’
compensation.
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Communication with family.
If you do not object or in an emergency
situation, we may disclose to a family member, other relative, close
personal friend, or any other person you identify PHI relevant to that
person’s involvement in your care or payment for such care.
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Disaster relief.
If you do not object or in an emergency
situation, we may use or disclose PHI in order to assist in disaster relief
efforts.
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Notification.
Unless you object, we may use or disclose
your PHI to notify, or assist in notifying, a family member,
personal representative, or other person responsible for your care about
your location, about your general condition, or about your death.
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Correctional Institutions.
If you are an
inmate of a correctional institution, we may disclose to the institution or
its agents the PHI necessary for your health and the health and safety of
other individuals
Exception to these Permitted Uses and Disclosures:
Communicable Diseases.
If you have one of several specific communicable diseases (for example,
tuberculosis, syphilis, or HIV/AIDS), North Carolina law requires that
information about your disease be treated as confidential, and such information
will be disclosed without your written permission only in limited
circumstances. We may not need to obtain your permission to report information
about your communicable disease to State and local officials or to otherwise use
or disclose information in order to protect against the spread of the disease.
Also, we may disclose such information without your consent to health care
personnel who provide medical care to you.
Special
Provisions for Minors under North Carolina Law:
Under North Carolina law, minors, with or without the consent of a parent or
guardian, have the right to consent to services for the prevention, diagnosis
and treatment of certain illnesses, including venereal disease and other
diseases that must be reported to the State, pregnancy, abuse of controlled
substances or alcohol, and emotional disturbance. If you are a minor and you
consent to one of these services, you have all the authority and rights included
in this Notice relating to that service. In addition, the law permits certain
minors to be treated as adults for all purposes. These minors have all rights
and authority included in this Notice for all services.
Any Other Use or
Disclosure of PHI:
Uses and disclosures of PHI other than those listed above will be made by
Kernodle Clinic only as otherwise authorized or required by law or with your
written authorization. If you sign a written authorization allowing us to
disclose PHI about you in a specific situation, you can later revoke your
authorization by submitting a written revocation to the Kernodle Clinic Privacy
Officer. Such revocation will be effective except to the extent that
information has already been used or disclosed or action has already been taken
in reliance thereon.
Your Health Information Rights
The health and billing records we maintain are the physical property of Kernodle
Clinic. The information in it, however, belongs to you. You have a right to:
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Request a restriction on certain
uses and disclosures of your PHI by delivering the request in writing to
Kernodle Clinic – we are not required to grant the request, but we shall
notify you if we deny your requested restriction, and we will comply with any
request granted;
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Obtain a paper copy of this Notice
of Privacy Practices by making a request to Kernodle Clinic;
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Request that you be allowed to
inspect and copy your health record and billing record – you may exercise this
right by delivering the request in writing to Kernodle Clinic using the form
we provide to you upon request;
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Appeal a denial of access to your
protected health information, except in certain circumstances;
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Request that your health care record
be amended to correct incomplete or incorrect information by delivering a
written request to Kernodle Clinic using the form we provide to you upon
request (However, Kernodle Clinic is not required to make such amendments);
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File a statement of disagreement if
your request for amendment is denied, and require that the request for
amendment and any denial be attached in all future disclosures of your
protected health information;
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Obtain an
accounting of disclosures of your PHI, as we are required to maintain by law,
by delivering a written request to our office using the form we provide to you
upon request. An accounting will not include internal uses of information for
treatment, payment, or operations, disclosures made to you or made at your
request, incidental uses or disclosures, or disclosures made to family members
or friends in the course of providing care; and
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Request that communications of your
health information be made by alternative means or at an alternative location
by delivering the request in writing to Kernodle Clinic using the form we give
you upon request – we shall accommodate all reasonable requests.
If you want to exercise any of the above rights,
please contact the Kernodle Clinic Privacy Officer at (336) 538-1234 or in
writing at 1234 Huffman Mill Road, Burlington, NC 27215. The Privacy Officer
will provide you with assistance on the steps to take to exercise your rights.
You
have the right to review this Notice before signing the attached Acknowledgment
form.
To
Request Information or File a Complaint
If you have questions, would like additional
information, or want to report a problem regarding the handling of your
information, you may contact our Privacy Officer, at (336) 538-1234 or in
writing at 1234 Huffman Mill Road, Burlington, NC 27215, ATTN: PRIVACY OFFICER.
Additionally, if you believe your privacy rights have
been violated, you may file a written complaint at our office by submitting a
written complaint to, Privacy Officer, (336) 538-1234, at 1234 Huffman Mill
Road, Burlington, NC 27215.
You
may also file a complaint by mailing it or e-mailing it to the Secretary of
Health and Human Services at:
Region IV, Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center
Suite 3B70, 61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Telephone: (404) 562-7886
Fax: (404) 562-7881
TDD: (404) 331-2867
E-mail: OCRComplaint@hhs.gov
We cannot, and will not, require you to waive the right to file a
complaint with the Secretary of Health and Human Services (HHS) as a condition
of receiving treatment from the office.
We cannot, and will not,
retaliate against you for filing a complaint with Kernodle Clinic or with the
Secretary of Health and Human Services.
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