BREEZEWOOD HEALTHCARE, P.A.
Post Office Box 87448
Fayetteville, North Carolina28304-7448
Phone: (910) 485-0700
Effective Date: 1 March 2012
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE
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 our Office Manager.
WHO WILL FOLLOW THIS NOTICE:
This notice describes our practices and that of
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the practice, whether made by our personnel or your primary care doctor. Your primary care doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
We reserve the right to make changes to this Notice and to make such changes effective for all Protected Health Information (PHI) we may already have about you. If and when this Notice is changed, we will post a copy in our office in a prominent location. We will also provide you with a copy of the revised Notice upon your request made to our Privacy Official.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of you, should you require care at Cape Fear Valley Health System, the FayettevilleAmbulatorySurgeryCenter, or other health care facility (e.g., home health care, etc.). For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, if you require hospital admission, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Also if you require hospital admission, different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the clinic or facility (hospital, ambulatory surgery center, etc.) who may be involved in your medical care after you leave the hospital, such as family members, clergy others we use to provide services that are part of your care.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive by one of our providers may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may use and disclose PHI for billing, claims management, and collection activities. We may disclose PHI to insurance companies providing you with additional coverage. We may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us. We may also disclose PHI to another health care provider or to a company or health plan required to comply with the HIPM Privacy Rule for the payment activities of that health care provider, company or health plan. For example, we may allow a health insurance company to review PHI for the insurance company's activities to determine the insurance benefits to be paid for your care.
For Healthcare Operations. We may use and disclose medical information about you for clinic operations. These uses and disclosures are necessary to run the clinic and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many clinic patients to decide what additional services the clinic should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other clinic personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the clinic.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health -Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital/clinic. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include one or more of the following:
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. We may also disclose medical information about you to the Corporation attorney in response to legal action.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
Organ and Tissue Donation. If you are an organ donor, we may use or disclose PHI to organizations that help procure, locate, and transplant organs in order to facilitate an organ, eye or tissue donation and transplantation.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a-law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the Institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding medical information we maintain about you.
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes or information gathered or prepared for a civil, criminal, or administrative proceeding.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Breezewood Healthcare, P.A., Post Office Box 87448, Fayetteville, North Carolina 28304-7448. If you request a copy of the information, we may charge a fee for the costs of copying, labor, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the clinic.
To request an amendment, your request must be made in writing and submitted to Breezewood Healthcare, P.A., Post Office Box 87448, Fayetteville, North Carolina 28304-7448. In addition, you must provide a reason that supports 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. In addition, we may deny your request if you ask us to amend information that
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than disclosures made for treatment, payment, and healthcare operations; for use in or related to a facility directory; to family members or friends involved in your care; to you directly; pursuant to an authorization of you or your personal representative, or for certain notification purposes (including national security, intelligence correctional, and law enforcement purposes) and disclosures made before April 14, 2003.
To request this list or accounting of disclosures, you must submit your request in writing to Breezewood Healthcare, P.A., Post Office Box 87448, Fayetteville, North Carolina 283047448. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a pregnancy you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Breezewood Healthcare, P.A., Post Office Box 87448, Fayetteville, North Carolina 28304-7448. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Breezewood Healthcare, P.A., Post Office Box 87448, Fayetteville, North Carolina 28304-7448. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, send request to:
Breezewood Healthcare, P.A.
Post Office Box 87448
Fayetteville, North Carolina 28304-7448
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the clinic. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you visit the clinic, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may rue a complaint with the clinic or with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, SW, Washington, D.C. 20201. To file a complaint with the clinic, contact the Administrator Privacy Officer at 485-0700. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
If you have any questions about this Notice, please contact our Office Manager (Privacy Official) at the address listed above or (910) 485-0700.
This Notice is effective in its entirety on March 1, 2012