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1069 Haywood Road        Asheville, NC 28806

September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Asheville Pain and Wellness Center (“APWC”), in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, (the “Privacy Rule”) and applicable state law, is committed to protecting the privacy of your protected health information (“PHI”). PHI includes information about your health condition and the care and treatment you receive from APWC. We understand that information about your health is personal. This Notice explains how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. APWC is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing our legal duties and practices with respect to your PHI. APWC is also required by law to abide by the terms of this Notice.

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 these categories.

For Treatment- We may use your PHI to provide you with treatment. We may disclose your PHI to doctors, nurses, technicians, clinicians, medical students, hospitals and other health facilities involved in or consulting in your care. We may also disclose information about you to people outside the practice, such as other health care providers involved in your care, such as family members, clergy, or others we use to provide services that are part of your care. If we refer you to another health care provider, we would, as part of the referral process share PHI information about you. For example, if you were referred to a specialist, we would contact the doctor’s office and provide such information about you to them so that they could provide services to you.

For Payment- We may use and disclose your PHI so we can be paid for the services we provide to you. For example, we may need to give your insurance company information about the health care services we provided to you so your insurance company will pay us for those services or reimburse you for amounts you have paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your condition and the health care you need to receive prior approval or to determine whether your plan will cover the services.

For Health Care Operations- We may use and disclose your PHI for our own health care operations and the operations of other individuals or organizations involved in providing your care. This is necessary for us to operate and to make sure that our patients receive quality health care. For example, we may use information about you to review the services we provide and the performance of our employees in caring for you.

Appointment Reminders/ Treatment Options- We may contact you for appointment reminders or to tell you about treatment options, alternatives or other health care related benefits/services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care- We may disclose to a family member, other relative,  a close friend, or any other person identified by you. Certain limited PHI that is directly related to that person’s involvement with your care or payment for your care. We may use or disclose your PHI to notify those persons of your location or general condition. This includes in the event of your death unless you have specifically instructed us otherwise. If you are unable to specifically agree or object, we may use our best judgment when communicating with your family and others.

Disaster Relief- We also may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts. This will be done to coordinate information with those organizations in notifying a family member, other relative, close friend or other individual of your location and general condition.

De-identified Information- We may use and disclose health information that may be relate to your care but does not identify you and cannot be used to identify you.

Business Associates- We may use and disclose information to those who perform functions on our behalf or provide us with services. For example, we may share your information with a billing company that helps us obtain payment from your insurance company. Our Business Associates are required through legal agreement to protect the privacy of your information and insure the use of safeguards to prevent any uses or disclosures not permitted other than as specified in the contracts.

Personal Representative- We may use and disclose PHI to a person who, under applicable law, has the authority to represent you in making decisions related to your care.

Emergency Situations- We may use and disclose PHI for the purpose of obtaining or rendering emergency treatment to you provided that we attempt to obtain your consent as soon as possible.

Public Health and Safety Activities- We may disclose your PHI for public health activities and purposes. This includes reporting information to a public health authority that is authorized by law to collect or receive the information. These activities generally include:

  • To prevent or control disease, injury or disability
  • To report births or deaths
  • To report child, elder, or dependent adult abuse or neglect
  • To report reactions to medications or problems with products
  • To notify people of recalls of products they may be using
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

Victims of Abuse, Neglect or Domestic Violence- We may disclose your PHI to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe an adult or child is a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is (a) required by law, (b) agreed to by you, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm, or, (d) if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
Health Oversight Activities- We may disclose your PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight agencies to monitor the nation’s health care system, government benefit programs, and for the enforcement of civil rights laws.

Judicial and Administrative Proceedings- We may disclose your PHI in response to a court or administrative order. We also may disclose information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.

Disclosures for Law Enforcement Purposes- We may disclose your PHI to law enforcement officials for these purposes:

  • As required by law
  • In response to a court, grand jury or administrative order, warrant or subpoena
  • To identify or locate a suspect, fugitive, material witness or missing person
  • About an actual or suspected victim of a crime if, under certain limited circumstances, we are unable to obtain that person’s agreement
  • To alert a potential victim or victims or intending harm (“duty to warn”)
  • To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct
  • About crimes that occur at our facilities
  • To report a crime, a victim of a crime or a person who committed a crime in emergency circumstances

To Avert Serious Threat to Health or Safety- We will use and disclose your PHI when we have a “duty to report” under state and federal law because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to help prevent a threat.

Coroners, Medical Examiners and Funeral Directors- We may disclose your PHI to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death. We also may disclose information to funeral directors so they can carry out their duties.

Organ, Eye or Tissue Donation- To facilitate organ, eye or tissue donation and transplantation, we may disclose your PHI to organizations that handle organ procurement, banking or transplantation.

Workers Compensation- We may disclose your PHI to the extent necessary to comply with worker’s compensation and similar laws that provide benefits for work-relates injuries or illness without regard to fault.

Special Government Functions- If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release information about foreign military authority. We may disclose information about you to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law.

Research- We may use and/or disclose your PHI for research projects that are subject to a special review process. If researchers are allowed access to information that identifies who you are, we will ask for your permission.

Fundraising- We may contact you with respect to fundraising campaigns. If you do not wish to be contacted for fundraising campaigns, please notify our Privacy Officer in writing.

AUTHORIZATION

The following uses and/or disclosures specifically require your express written permission:

Marketing Purposes- We will not use or disclose your PHI for marketing purposes for which we have received payment without your express written permission. However, we may contact you with information about products, services or treatment alternatives directly related to your treatment and care.

Sale of Health Information- We will not sell your PHI without your written authorization. If you do authorize such a sale, the authorization will disclose that we will receive compensation for the information that you have authorized us to sell. You have the right to revoke the authorization at any time, which will halt any future sale. Uses and/or disclosures other than those described in this Notice will be made only with your written authorization. If you do authorize a use and/or disclosure, you have the right to revoke that authorization at any time by submitting a revocation in writing to our Privacy Officer. However, revocation cannot be retroactive and will only impact uses and/or disclosures after the date of the revocation.

YOUR RIGHTS

Right to Revoke Authorization- You have the right to revoke any Authorization or consent you have given APWC, at any time. To request a revocation, you must submit a written request to our Privacy Officer.

Right to Request Restrictions- You have the right to request that we restrict the uses or disclosures of your information for treatment, payment or healthcare operations. You may also request that we limit the information we share about you with a relative or friend of yours. You also have the right to restrict disclosure of information to your commercial health insurance plan regarding services or products that you paid for in full, out-of-pocket and we will abide by that request unless we are legally obligated to do so.     We are not required to agree to any other requested restriction. If we agree, we will follow your request unless the information is needed to a) give you emergency treatment, b) report to the Department  Required or Permitted By Law” section. To request a restriction, you must have your request in writing to our Privacy Officer. You must tell us: a) what information you want to limit, b) whether you want to limit use or disclosure or both and c) to whom you want the limits to apply. Either you or we can terminate restrictions at a later date.

Right to Inspect and Copy- You have the right to inspect and request copies of your information. To inspect or copy your information, you may either complete an Authorization to Release/Obtain Information form or write a letter of request, stating the type of information to be released, the date(s) of service being requested, the purpose of the request, and whether you wish to review the record or receive copies of the requested information in your preferred format. We will abide by your request in the format you have requested, if we are able to do so. If we cannot provide your records to you in the requested format, we will attempt to provide them in an alternative format that you agree to. You may also request that your records be sent to another person that you have designated in writing. Direct this request to our Privacy Officer. You may be charged a fee for the cost of copying, mailing or other expenses related with your request.

We may deny your request to inspect and copy information in a few limited situations. If your request is denied, you may ask for our decision to be reviewed. APWC will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be te person who denied your request. We will comply with the outcome of that review.

Right to Amend- If you feel that your PHI is incorrect, you have the right to ask us to amend it, for as long as the information is maintained by us. To request an amendment, you must submit your request in writing to the Privacy Officer. You must provide a reason for the amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason for wanting the amendment. We may also deny your request if the information: a) was not created by us, unless the person or entity that created the information is no longer available to amend the information, b) is not part of the information maintained by APWC, c) is not information that you would be permitted to inspect and copy or d) is accurate and complete.

Right to an Accounting of Disclosures- You have the right to request an accounting of disclosures. This is a list of certain disclosures we have made regarding your PHI. To request an accounting of disclosures, you must write to our Privacy Officer. Your request must state a time period for the disclosures. The time period may be for up to six years prior to the date on which you request the list, but may not include disclosures made before April 14, 2003.

There is no charge for the first list we provide to you in any 12-month period. For additional lists, we may charge you for the cost of providing  the list. If there will be a charge, we will notify you of the cost in advance. You may withdraw or change your request to avoid or reduce the fee.

Certain types of disclosures are not included in such an accounting. These include disclosures made for treatment, payment or healthcare operations; disclosures made to you or for our facility directory; disclosures made with your authorization; disclosures for national security or intelligence purposes or to correctional institutions or law enforcement officials in some circumstances.

Right to a Paper Copy of this Notice- You have the right to receive a paper copy of this Notice of Privacy  Practices, even if you have agreed to receive this Notice electronically. You may request a paper copy of this Notice at any time.

Right to File a Complaint- You have the right to complain to APWC or to the United States Secretary of Health and Human Services (as provided by the Privacy Rule) if you believe your privacy rights have been violated. To file a complaint with APWC, you must contact our Privacy Officer. To file a complaint with the United States Secretary of Health and Human Services, you may write to: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Room 509F, HHH Building, Washington, DC 20201, telephone: 202-619-0257, email: ocrmail@hhs.gov; or to the North Carolina Attorney General, 9001 Mail Service Center, Raleigh, NC 2769909001, telephone: 919-716-6400. All complaints to our office must be in writing.To obtain more information about your privacy rights or if you have any questions about your privacy rights you may contact our Privacy Officer as follows:

Asheville Pain and Wellness Center 1069 Haywood Road, Asheville NC 28806

Telephone: 828-258-2225

We encourage your feedback and we will not retaliate against you in any way for the filing of a complaint. APWC reserves the right to change this Notice and make the revised Notice effective for all health information that we had at the time, and any information we create or receive in the future. We will distribute any revised Notice to you prior to implementation.

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