NOTICE OF PRIVACY PRACTICES

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. Our staff is committed to protecting your information, which is a right you have and one detailed in the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Effective: January 3, 2005

If you have any questions or requests, please contact the Conner Family Health Clinic at 704- 708-4301.

     1. WE MUST PROTECT HEALTH INFORAMTION ABOUT YOU:

We must protect the privacy of your protected health information or “PHI” for short. This Notice explains the ways that we will use your PHI. It also explains the ways that we will share or disclose PHI about you. In addition, we may make other uses and disclosures that occur as a result of the permitted uses and disclosures described in this Notice.

We must follow this Notice. We may change this Notice. We may make the changes apply to all PHI that we already have. If we do so, we will:

 Post the new notice in our offices

 Make copies of the new notice available if someone asks for it.

2. WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR PERMISSION IN CERTAIN SITUATIONS.

A. We may use and disclose your PHI to provide health care treatment to you.

We may use and disclose your PHI to provide, coordinate, or manage your health care and related services. This may include sharing information with other health care providers about your treatment and coordinating and managing your health care with others. For example, we may use and disclose your PHI when we refer you to another health care provider.

B. We may use and disclose your PHI to obtain payments for services.

Generally, we may use and give your PHI to others to bill and collect payment for services. Before we provide scheduled services, we may share information with your health plan(s) so that we can ask whether your plan or policy will pay for the service. We may also share PHI with:

 Billing departments

 Collection departments or agencies

 Insurance companies, health plans and their agents who provide coverage

 Hospital departments that review your care to see if the care and the costs were appropriate

 Government agencies to try to get you qualified for benefits

 Consumer reporting agencies (such as credit bureaus)

 Other departments, agencies and/or companies to obtain payment

C. We may use and disclose your PHI for health care operations

We may use and disclose PHI to perform business activities, which we call “health care operations.” These “health care operations” allow us to improve quality of care we provide and reduce health care costs. Examples of the way we may use or disclose your PHI for “health care operations” include:

 Reviewing and improving the quality, efficiency and cost of care that we provide to you and others. For example, we may use your PHI to develop ways to help our health care providers and staff in deciding what medical treatment should be given to others.

 Improving health care and lowering costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of people. We may use PHI to identify groups of people with similar health problems to give them information about treatment choices, classes, or new procedures.

 Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.

 Training health care providers or other professionals (for example, billing clerks or assistants) to help them practice or improve their skills

 Working with outside organizations that assess the quality of the care that we and other provide. These organizations might include government agencies or accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations.

 Working with outside organizations that evaluate, certify or license health care providers, staff or facilities in a given field or specialty.

 Helping people who review our activities. For Example, PHI may be seen by doctors reviewing the services provided to you and by accountants, lawyers, and others who help us in following the law.

 Solving patient problems and complaints within our clinic

 Reviewing activities and using or disclosing PHI in the event that we sell our business or property, or give control of our business or property to someone else.

D. We may use and disclose PHI in other situations without your permission

We may use and/or disclose PHI about you without your permission. Those situations include when the use and/or disclosure:

 Is required by law

 Is needed for public health activities

 Is about the abuse or neglect of a child or disabled adult

 Is for police or other law enforcement purposes

 Relates to a person who had died

 Related to organ, eye or tissue donation

 Related to medical research. In certain situation, we may share your PHI for medical research

 Is to prevent a serious threat to public health or safety

 Relates to someone who is in jail, prison or in police custody

E. You can object to certain uses and disclosures. Unless you tell us not to, we may share your PHI as follows:

 We may share your PHI with a family member, friend or other person identified by you. We may share information directly related to that person’s involvement in your care or payment for your care. We also may share PHI needed to let these people know where you are, your general condition or your death.

 We may share your PHI with a public or private agency (for example, American Red Cross) for disaster relief purposes. Even if you ask us not to, we may share your PHI, in the case of an emergency.

 If you do not want us to use or disclose your Phi in the above situations, please tell the person you registered with.

F. We may contact you to remind you of an appointment

We may use and/or disclose PHI to contact you to remind you about an appointment you have for treatment or medical care

G. 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 health care. This may include telling you about treatments, services, products and/or other health care providers. We may also use and/or disclose PHI to give you gifts of small value.

ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES YOUR WRITTEN PERMISSION

In any situation other than those listed above, we will ask for your written permission before we use or disclose your PHI. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing. We will not disclose PHI about you after we receive your cancellation, except for disclosures that were made before your written cancellation. Below are specific circumstances in which we will require a written consent:

 Release of psychotherapy notes

 Disclosures for marketing purposes

 Disclosures for any purposes which require the sale of PHI

3. YOU HAVE SEVERAL RIGHTS REGARDING YOUR PHI

A. You have the right to ask us to restrict the uses and disclosures of your PHI You have the right to ask that we restrict the use and disclosure of your PHI. You may ask us in writing. We do not have to agree to your request. Even if we agree to your request, in certain circumstances your restrictions may be revoked. You may ask for a restriction by filling out a form that you can get from the registration desk or your caregiver. We will write you to tell you if the request was granted.

B. You have the right to ask for different ways to communicate with us.

You have the right to ask how and where we can contact you about PHI. This information is provided on your intake forms filled out during your first visit and once every year after that.

C. You have the right to see and copy your PHI

You have the right to see and get a copy of your PHI. You must ask us in writing. We may charge you a fee for your printed records.

D. You have the right to ask for changes to your PHI You have the right to ask us to make changes to your PHI. You must ask us in writing, however, we reserve the right to deny any changes.

E. You have the right to a list of certain people or organizations who have gotten your PHI from our facility.

If you ask in writing, you can get a list of disclosures of your PHI. You may ask for disclosures made in the last six (6) years. We cannot give you a list of any disclosures made before January 3, 2005. If you ask for a list of disclosures more than once in 12 months we can charge you a reasonable fee.

F. You have the right to a copy of this Notice.

G. You have the right to restrict certain disclosures for PHI to a health plan where the individual pays out of pocket in full for the health care item or service

H. You will be notified in the event that a breach of HIPAA has been committed.

I. You will be notified of use of PHI for fundraising communications and be given the opportunity to opt out.

You can get a copy of this Notice by asking at the registration desk.

4. YOU MAY HAVE ADDITIONAL RIGHTS UDER OTHER LAWS

Some North Carolina laws give greater protection of privacy than federal laws. We must follow both federal and state law. These North Carolina laws may apply to our treatment of you:

 North Carolina law protects the privacy of PHI about mental health treatment. Before sharing mental health information about you with others for treatment, payment or health care operations, we will ask that you sign a form giving us permission to share that information.

 If you ask for treatment and rehabilitation for drug abuse, your request will be confidential. We will not give your name to any police officer or other law enforcement officer unless you give us permission to do so. Even if we refer you to another person for help, we will keep your name confidential.

 If you have a communicable disease (i.e., lubercolsis, syphilis, or HIV/AIDS), information about your disease will be kept confidential, and we will get your permission except in limited circumstances. For example, we will get your permission to share this information about your disease to state and local health officials or to prevent the spread of disease.

We may also release information about you if we reasonable believe that the release is necessary to protect someone’s life or health, or prevent a serious danger of violence.

 North Carolina law generally requires that we get your written permission before we may share health information about your mental health, developmental disabilities or substance abuse services. There are some expectations to this requirement. We can share this information without workers, professional advisors, and to agencies or individuals that oversee our operations or that help us serve you. We may also disclose information to: (1) a health care provider who is treating you in an emergency, (2) a healthcare provider who referred you to us, if they ask and (3) to other mental health, developmental disabilities and substance abuse facilities or professional when necessary to coordinate your care of treatment. If we believe that there is an immediate threat to the health or safety of you or someone else, we may share information to prevent or reduce the harm. Sometimes the law makes us share information about you. For example, a court might order disclosure. We have to share information when we believe that a child or disabled adult is being abused or neglected. We also must share information if you have a certain disease or are infected with HIV/AIDS and one of our doctors believes that you a re not following safety measures. If we believe it is in your best interest, we may share information about you to get a guardian for you or to commit you to a mental health facility against your wishes. When you are admitted to or discharged from a mental health developmental disability, or substance abuse facility, we may tell your family if we believe that sharing this information is in your best interest. However, if you ask us not to tell your family, then we generally won’t tell them. If you have a family member who is very involved in your care, if he or she asks us to, then we must provide information about your admission or discharge from a facility, including the name of the facility, any decisions by you to leave a facility against medical advice and referrals and appointments for treatment after discharge.

 If you apply for or receive substance abuse services from us, federal law generally requires that we get your written permission before we share information that would identify you as a substance abuser or a patient of substance abuse services. There are some expectations to this rule. We can share this information with our workers to coordinate your care and to agencies or individuals that help us serve you. We may share information with medical workers in an emergency. If we believe that a child is abused or neglected, we must report the abuse or neglect to the Department of Social Services, and we may share substance abuse treatment information when making the report. We will disclose information to obey a court order. If you commit a crime, or treatment to commit a crime on our property or against our workers we may report this to the police. If you threaten to harm another person, we may notify that person as well as the police.

Special provisions for persons under age 18: Under North Carolina law, persons under the age of 18 may give permission for services to prevent, diagnose and/or treat certain illnesses including but not restricted to: sexually transmitted diseases and other diseases that must be reported to the state (such as HIV), pregnancy, abuse of drugs or alcohol, and emotional disturbances. In general, a person under the age of 18 cannot terminate a pregnancy unless she has the permission from a parent, guardian or grandparent with whom she has been living for at least six (6) months. The only way to terminate a pregnancy without this permission is if a court orders that the person under age 18 can make this decision for herself. If you are under that age or 18 and you give permission for one of these services, you have all the rights stated in this Notice relating to that service. If you are under the age of 18 and you have been married, are a member of the armed services or have been emancipated by a judge, then you have the right to be treated as an adult for all purposes. This means that you have all the rights stated in this Notice for all services.

5. 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 may contact us. You may also write 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