NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
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.
With your consent, the practice is permitted by federal privacy laws to make uses and discloser of your health
information for purposes of treatment, payment and health care operations. Protected health information is the
information we create and obtain in providing our services to you. Such information may include documenting your
symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also
includes billing documents for those services.
Examples of uses of your health information for treatment:
An assistant obtains treatment information about you and records it in a health record. During the course of your
treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the
information with such specialist and obtain input.
Examples of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health insurance company requests
information from us regarding medical care given. We will provide information to them about you and your care given.
Examples of use of your information 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 and other business associates
as necessary to obtain these services.
The practice is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with notice of our duties and privacy practices as to the information we collect and maintain
about you;
• Abide by the terms of this notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, or eliminate provisions in our privacy practices and access practices and to enact hew
provisions regarding the protected health information we maintain. If our information practices change, we will amend
our notice. 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.
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 the Practice Administrator 910/485-1191.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by
delivering a written complaint to the Practice Administrator. You may also file a complaint by mailing it our emailing it
to the Secretary of Health and Human Services whose street address is 2001 Mail Service Center, Raleigh NC
27699, Carmen.hookerodem@ncmail.net.
• We cannot and will not request to waive the right to file a complaint with the Secretary of Health and Human
Services (HHS) as a condition of receiving treatment for the practice.
• We cannot and will not retaliate against you for filing a complaint to the Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family
member, personal representative, or other person responsible for your care, about your location and about your
general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family, other relative, close personal friend, or any other person you
identify, health information relevant to that person's involvement in your care or in payment for such care if you do not
object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products ad
product defects, or post marketing surveillance information to enable product, recalls repairs or replacements.
Workers Compensation
If you are seeking compensation the Workers Compensation, we may disclose your protected health information to
the extent necessary to comply with laws relating to Workers Compo
Public Health
As required by law, we may disclose your protected health information to public authorities as allowed by law to
report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution or its agents, your protected health
information necessary for your health and safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when
required by a court order, or in cases involving felony prosecutions, or to the extent and individual is in the custody of
law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for
health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as
allowed or required by law, with your consent or as directed by a proper court order.
Other Uses
Other uses and disclosure besides those identified in this notice will be made only as otherwise authorized by law or
with your written authorization and you may revoke the authorization as previously provided.
Your Health Information Rights
The health record we maintain an billing records are the physical property of the practice. The information in it
however, belongs to you. You have a right to:
• Request a restriction on certain uses and disclosures of your health information by delivering the request in
writing to our office. We are not required to grant the request, but we will comply with any request granted.
• Request 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 our office;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request your health care record to be amended to correct incomplete or incorrect information by delivering
a written request to our office;
• File a statement of disagreement if your amendment is denied, and require the request for amendment and
any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as required to be maintained by law by
delivering a written request to our office. An accounting will not include internal uses of information for
treatment, payment or operations, disclosures made to family members or friends in the course of providing
care;
• Request that communication of your health information be made by alternative means or an alternative
location by delivering a written request to our office; and,
• Revoke authorizations you made previously to use or disclose information except to the extent information
or actions have already been taken by delivering a written request to our office.
If you want to exercise any of the above rights, please contact the Practice Administrator, 910/485-1191, in person or
in writing, during normal business hours. She will provide you with assistance on the steps to take to exercise your
rights.
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