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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. |
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This Notice of Privacy Practices
describes how we may use and disclose your protected health
information (PHI) to carry out treatment, payment or health
care operations (TPO) and for other purposes that are
permitted or required by law. |
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It also describes your rights to
access and control your protected health information.
"Protected Health Information" is information about you,
including demographic information, that may identify you and
that relates to your past, present or future physical or
mental health or condition related health care services. |
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We are required to provide this
notice to you by the Health Insurance Portability and
Accountability Act (HIPAA). |
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Forms |
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Uses and Disclosures or Protected Health Information |
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Your
Rights |
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Complaints |
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Contact Information |
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FORMS |
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You will need
Adobe Acrobat to read and print these forms. |
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USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION |
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Your protected health information
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, to pay your health care bills, to support the
operation of the physician's practice, and any other use
required by law. |
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Treatment:
We will use and disclose your protected health information to
provide, coordinate, or manage your health care and any
related services. This includes the coordination or
management of your health care with a third party. For
example, we would disclose your protected health information,
as necessary, to a home health agency that provides care to
you. For example, your protected health information may
be provided to a physician to whom you have been referred to
ensure that the physician has the necessary information to
diagnose or treat you. |
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Payment:
Your protected health information will be used, as needed, to
obtain payment for your health care services. For
example, obtaining approval for a hospital stay may require
that your relevant protected health information be disclosed
to the health plan to obtain approval for the hospital
admission. |
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Healthcare Operations:
We may use or disclose, as needed, your protected health
information in order to support the business activities of
your physician's practice. These activities include, but
are not limited to, quality assessment activities, employee
review activities, training of medical students, licensing,
and conducting or arranging for other business activities.
For example, we may disclose your protected health information
to medical school students that see patients at our office.
In addition, we may use a sign-in sheet at the registration
desk where you will be asked to sign your name and indicated
your physician. We may also call you by name in the
waiting room when your physician is ready to see you. We
may use or disclose your protected health information, as
necessary, to contact you to remind you of your appointment. |
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We will share you protected health
information with third-party "business associates" who perform
various activities (for example, billing, transcription
services, etc.) for any health plan. The business
associates will also be required to protect your health
information. |
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We may use or disclose your
protected health information in the following situations
without your authorization. These situations include: as
Required by law, Public Health issues as required by law, and
Communicable Diseases; Health Oversight; Abuse or Neglect;
Food and Drug Administration requirements; Legal Proceedings;
Law Enforcement; Coroners, Funeral Directors and Organ
Donation; Research; Criminal Activity; Military Activity and
National Security; Workers' Compensation; Inmates; Required
Uses and Disclosures; Under the law we must make disclosures
to you, and when required by the Secretary of Health and Human
Services, to investigate or determine our compliance with the
requirements of Section 164.500. |
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Other Permitted and Required Uses and Disclosures:
will be made only with your consent, authorization or
opportunity to object unless required by law. |
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You may revoke this
authorization, at any time, in writing, except to the
extent that your physician or the physician's practice has
taken an action in reliance on the use or disclosure indicated
in the authorization. |
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YOUR RIGHTS |
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Following is a statement of your
rights with respect to your protected health information. |
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You have the right to inspect and
copy your protected health information. |
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Under Federal Law, however, you may not inspect of copy the
following records: psychotherapy notes; information complied
in reasonable anticipation, or use in, a civil, criminal, or
administrative action or proceeding; and protected health
information that is subject to law that prohibits access to
protected health information. |
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You have the right to request
a restriction of your protected health information. |
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This means you may ask us not to use
or disclose any part of your protected health information for
the purposes to treatment, payment or healthcare operations.
You may also request that any part of your protected health
information not be disclosed to family members or friends who
may be involved in your care or for notification purposes as
described in this Notice of Privacy Practices. Your
request must state the specific restriction requested and to
whom you want the restriction to apply. |
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Your physician is not required to
agree to a restriction that you may request. If your
physician believes it is in your best interest to permit use
and disclosure of your protected health information, your
protected health information will not be restricted. You
then have the right to use another Healthcare Professional. |
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You have the right to request
to receive confidential communications from us by alternative
means or at an alternative location. You have the right to obtain a paper copy of this notice
from us. |
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Upon request, even if you have
agreed to accept this notice alternatively (i.e.
electronically). |
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You may have the right to have
your physician amend your protected health information. |
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If we deny your request
for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such
rebuttal. |
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You have the right to receive
an accounting of certain disclosures we have made, if any, of
your protected health information. |
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We reserve the right to change the
terms of this notice and will inform you by mail of any
changes. You then have the right to object or withdraw
as provided in this notice. |
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COMPLAINTS |
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You may complain to us or to the
Secretary of Health and Human Services if you believe your
privacy rights have been violated by us. |
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You may file a complaint with us by
notifying our privacy contact of your complaint. |
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We will not retaliate against
you for filing a complaint. |
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This notice is effective in its
entirety as of April 14, 2003. |
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CONTACT INFORMATION |
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We are required by law to maintain
the privacy of, and provide individuals with, this notice of
our legal duties and privacy practices with respect to
protected health information. |
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If you have any objections to this
form, you may contact our privacy officer by mail at Privacy
Officer, PO Drawer B, Mamers, NC 27552, by phone at (910)
893-5402 or by email at
privacy@firstchoicechc.org. |
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