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NOTICE OF PRIVACY PRACTICES

We are committed to protect the privacy of your personal health information (PHI).

This Notice of Privacy Practices (notice) describes how medical information about you may be used and disclosed to carry out treatment, payment or health care operations. We may also share your information for other purposes that are permitted or required by law. This notice also describes your rights to access and control your PHI.

We are required by law to maintain the privacy of your PHI. We will follow the terms outlined in this notice.

Please review it carefully.

Uses and Disclosures of Protected Health Information
How do we typically use or share your health information? We typically use or share your health information in the following ways.
To provide health care treatment for you
  • Your PHI 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.
    • EXAMPLE: Your PHI may be provided to a physician to whom you have been referred for evaluation to ensure that the physician has the necessary information to diagnose or treat you. We may also share your PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
  • We may also share your PHI with people outside of our practice that may provide medical care for you such as home health agencies.
To obtain payments for your services
  • We may provide your PHI to others in order to bill or collect payment for services. There may be services for which we share information with your health plan to determine if the service will be paid for.
  • PHI may be shared with the following:
    • Billing companies
    • Insurance companies, health plans
    • Government agencies in order to assist with qualification of benefits
    • Collection agencies
  • EXAMPLE: You are seen at our practice for a procedure. We will need to provide a listing of services such as x-rays to your insurance company so that we can get paid for the procedure. We may at times contact your health care plan to receive approval PRIOR to performing certain procedures to ensure the services will be paid for. This will require sharing of your PHI.
To support business operations
  • We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
  • EXAMPLES:
    • Manage your treatment and services
    • Training students, other health care providers, or ancillary staff such as billing personnel to help them learn or improve their skills.
    • Quality improvement processes which look at delivery of health care and for improvement in processes which will provide safer, more effective care for you.
    • Use of information to assist in resolving problems or complaints within the practice.
We may use and disclose your PHI in other situations without your permission
  • If required by law:
    • The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. For example, we may be required to report gunshot wounds or suspected abuse or neglect.
  • Public health activities:
    • The disclosure will be made for the purpose of controlling disease, injury or disability and only to public health authorities permitted by law to collect or receive information. We may also notify individuals who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
  • Health oversight agencies:
    • We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
  • Legal proceedings:
    • To assist in any legal proceeding or in response to a court order, in certain conditions in response to a subpoena, or other lawful process.
  • Police or other law enforcement purposes:
    • The release of PHI will meet all applicable legal requirements for release.
  • Coroners, funeral directors:
    • We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law
  • Medical research:
    • We may disclose your protected health information 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 protected health information.
  • Special government purposes:
    • Information may be shared for national security purposes, or if you are a member of the military, to the military under limited circumstances.
  • Correctional institutions:
    • Information may be shared if you are an inmate or under custody of law which is necessary for your health or the health and safety of other individuals.
  • Workers’ Compensation:
    • Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
How else can we use or share your health information?
  • Business Associates:
    • Some services are provided through the use of contracted entities called “business associates”. We will always release only the minimum amount of PHI necessary so that the business associate can perform the identified services. We require the business associate(s) to appropriately safeguard your information. Examples of business associates include billing companies or transcription services.
  • Health Information Exchange:
    • We may make your health information available electronically to other healthcare providers outside of our facility who are involved in your care. 
  • Treatment alternatives:
    • We may provide you notice of treatment options or other health related services that may improve your overall health.
  • Appointment reminders:
    • We may contact you as a reminder about upcoming appointments or treatment.
Your Privacy Rights
You have certain rights related to your protected health information. All requests to exercise your rights must be made in writing.
To see and obtain a copy of your protected health information.
  • You can ask to see or get a copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request.
  • We may charge a reasonable, cost-based fee.
Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If we do agree to a restriction request we will honor the restriction unless the information is needed to provide emergency treatment. 
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  • We will say “yes” unless a law requires us to share that information. 
Request for us to communicate in different ways or in different locations
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.
  • We will not ask for an explanation from you about the request.
Ask us to correct your medical record
  • You may request an amendment of your health information if you feel the information is incorrect or incomplete. Ask us how to do this.
  • We may not be able to grant your request, but we’ll tell you why in writing within 60 days.
Get a list of those with whom we’ve shared information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • This right applies to all disclosures for purposes other than treatment, payment, or healthcare operations.
  • We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. 
Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting our office at 336-299-8530. Ask to speak to Shannon Lewis. 
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, we may use or disclose your information UNLESS you object:
  • Share information with your family, close friends, or others involved in your care
  • Share information to an authorized public or private entity to assist in a disaster relief situation
  • We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
  • If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety
In these cases we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes
Our Responsibilities
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
  • For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice 
We may change this notice, at any time, and any changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.


Effective Date: April 14, 2003
I hereby acknowledge that I have received a copy of this offices Notice of Privacy Practices. I may refuse to sign this acknowledgement. To obtain a paper copy I may request it from the office or the website.

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