3125 Springbank Ln.
Charlotte, NC 28226
1450 Matthews Township Pkwy
Matthews, NC 28105
NOTICE OF PRIVACY PRACTICES OF
ARBORETUM OBSTETRICS & GYNECOLOGYTHIS 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.
If you have any questions or requests, please contact:
Privacy Officer: Alia Paige
Arboretum Obstetrics and Gynecology
3125 Springbank Ln
Charlotte, NC 28226
A. We Have A Legal Duty to Protect Health Information About You
We are required by law to protect the privacy of health information about you and that can be identified with you, which we call “protected health information,” or “PHI” for short. We must give you notice of our legal duties and privacy practices concerning PHI:
This Notice describes the types of uses and disclosures that we may make and gives you some examples. In addition, we may make other uses and disclosures which occur as a byproduct of the permitted uses and disclosures described in this Notice. If we participate in an “organized health care arrangement” (defined in subsection B.3 below), the providers participating in the “organized health care arrangement” will share PHI with each other, as necessary to carry out treatment, payment or health care operations (defined below) relating to the “organized health care arrangement”.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:
B. We May Use and Disclose PHI About You Without Your Authorization in the Following Circumstances
1. We may use and disclose PHI about you 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. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider.
EXAMPLE : Your doctor may share medical information about you with another health care provider. For example, if you are referred to another doctor, that doctor will need to know if you are allergic to any medications. Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.
2. We may use and disclose PHI about you to obtain payment for services.
Generally, we may use and give your medical information to others to bill and collect payment for the treatment and services provided to you by us or by another provider. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions of medical information about you with the following:
EXAMPLE: Let’s say you come in for treatment. We may need to give your health plan(s) information about your condition, supplies used, and services you received. The information is given to our billing department and your health plan so we can be paid or you can be reimbursed.
3. We may use and disclose PHI about you for health care operations.
We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. We may also disclose PHI for the “health care operations” of any “organized health care arrangement” in which we participate. An example of an “organized health care arrangement” is the care provided by a hospital and the physicians who see patients at the hospital. In addition, we may disclose PHI about you for the “health care operations” of other providers involved in your care to improve the quality, efficiency and costs of their care or to evaluate and improve the performance of their providers. Examples of the way we may use or disclose PHI about you for “health care operations” include the following:
4. We may use and disclose PHI under other circumstances without your authorization or an opportunity to agree or object.
We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:
5. You can object to certain uses and disclosures.
Unless you object, we may use or disclose PHI about you in the following circumstances:
If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call or write to our contact person listed on the cover page of this Notice.
6. We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
7. We may contact you with information about treatment, services, products or health care providers.
We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value.
EXAMPLE: If you are diagnosed with a certain condition, we may tell you about nutritional and other counseling services that may be of interest to you.
C. You Have Several Rights Regarding PHI About You
1. You have the right to request restrictions on uses and disclosures of PHI about you.
You have the right to request that we restrict the use and disclosure of PHI about you. We are not required to agree to your requested restrictions. However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection B.4 of the previous section of this Notice. You may request a restriction by completing the form, “Request for Limitation on Disclosure,” which is available at the front desk. The practice’s Privacy Officer will evaluate your request.
2. You have the right to request different ways to communicate with you.
You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by completing the form “Request to Receive Communications by Alternative Means,” which is available at the front desk. The practice’s Privacy Officer will evaluate your request.
3. You have the right to see and copy PHI about you.
You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. Your request must be in writing. We may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial. You may request to see and receive a copy of PHI by completing the form “Request for Access to Patient’s Health Information,” which is available at the front desk.
4. You have the right to request amendment of PHI about you.
You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described in paragraph 3 above. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment. You may request an amendment of PHI about you by contacting the practice’s Privacy Officer in writing.
5. You have the right to a listing of disclosures we have made.
If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of PHI about you. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003). We are required to provide a listing of all disclosures except the following:
The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.
If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by completing the form “Request for Accounting of Disclosures” which is available at the front desk.
6. You have the right to a copy of this Notice.
You have the right to request a paper copy of this Notice at any time by contacting a staff member. We will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).
D. 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. Regarding abortion services, however, North Carolina law requires the consent of both the minor and the parent, guardian or a grandparent with whom the minor has been living for at least six (6) months, unless a court has determined that the minor alone can consent to the abortion. 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.
E. You May File A Complaint About Our Privacy Practices
If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the practice’s Privacy Officer listed above.
You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.
If you file a complaint, we will not take any action against you or change our treatment of you in any way.
F. Effective Date of this Notice
This Notice of Privacy Practices is effective on April 14, 2003.
I have read Arboretum Obstetrics and Gynecology’s Notice of Privacy Practices and fully understand the provisions listed herein.
3125 Springbank Ln.
Charlotte, NC 28226
1450 Matthews Township Pkwy
Matthews, NC 28105