Notice of Privacy Practice

Effective Date: April 14, 2003
This Version Effective:  February 28, 2010

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:

• We must maintain the privacy of your PHI as required by law;
• 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
• We must abide by the terms of this Notice that are 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 this Notice 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

1.   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.

Examples of uses of your PHI for treatment purposes:

• A nurse obtains treatment information about you and records it in a health record.
• 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.

2.   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:

• We submit requests for payment to your health insurance company. The health insurance company(or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.

3.   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:

• 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.

4.   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:

• 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.
• Public health activities. As permitted by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability.  In addition, 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.
• Abuse and neglect. We may disclose your PHI to public authorities as allowed by law to report abuse or neglect.
• 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.
• Organ donation and procurement organizations. Consistent with applicable law, we may disclose your PHI to organ donation and procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Health oversight activities. We may disclose your PHI to appropriate health oversight agencies for oversight activities authorized by law including licensure, audits, and investigations.
• 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.
• 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.
• 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.
• 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.
• Specialized government functions. We may disclose your PHI for specialized government functions as authorized by law – for example, for appropriate military purposes, or the conduct of national security and intelligence activities.
• Workers’ compensation. We may disclose your PHI to the extent necessary to comply with laws relating to workers’ compensation.
• 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.
• 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.
• 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.
• 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.

Other Reasons We May Contact You:

• We may use or disclose PHI to contact you to provide appointment reminders.
• We may use or disclose PHI to manage your healthcare and provide you with information about treatment alternatives, services, and products that may be of interest to you.
• We may use or disclose demographic information about you and the dates you received treatment or services to contact you about fundraising activities for Kernodle Clinic, but you will be given the opportunity to opt out of any subsequent fundraising activities.

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:

• Request a restriction on certain uses and disclosures of your PHI by delivering the request in writing to Kernodle Clinic – in most cases, 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.  If you request a restriction on disclosures to a health plan for payment or health care operations purposes regarding services for which you have paid in full, then we will comply with that request;
• Obtain a paper copy of this Notice of Privacy Practices by making a request to Kernodle Clinic;
• 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.  In addition, if we maintain your PHI in an electronic record, you have a right to receive an electronic copy of that PHI, and you may request that we transmit an electronic copy of your PHI, or a summary or explanation of the record, directly to an entity or person which you designate;
• Appeal a denial of access to your protected health information, except in certain circumstances;
• 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);
• 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 PHI;
• 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. Currently, an accounting will not include uses of information for treatment, payment, or health care operations, disclosures made to you or made at your request, incidental uses or disclosures, disclosures made for national security, disclosures made to family members or friends in the course of providing care, disclosures to correctional institutions or to law enforcement officials, or disclosures which are part of a limited set of information which does not contain certain information which would identify you.  Starting on January 1, 2014, we will also include in our accounting disclosures made through our electronic health records for treatment, payment, or health care operations.  If you request a list of disclosures more than once in twelve months, we can charge you a reasonable fee; and
• 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 Kernodle Clinic or its physicians.

We cannot, and will not, retaliate against you for filing a complaint with Kernodle Clinic or with the Secretary of Health and Human Services.