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.
| I. |
OUR RESPONSIBILITIES |
| |
Lakeshore Pediatric Center,
is required by law to maintain the privacy of your
protected health information and to provide you
with this Notice that explains how, when and why
we use and disclose your protected health information.
We are required by law to follow the privacy practices
that are described in this Notice. We reserve the
right to change this Notice and our privacy policies
at any time. Any such changes will apply to the
protected health information we already have. Before
we make an important change to our policies, we
will change this Notice and post a new notice in
our office and on our website. You can also request
a copy of this Notice or any revised notice from
the contact person listed in Section V. below at
any time. |
| |
|
| II. |
HOW WE MAY USE
AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
|
| |
Lakeshore Pediatric Center
uses and discloses the health information of its
patients for many different reasons. In this Notice,
to "use" protected health information means that
we are sharing that information with someone who
is a member of Lakeshore Pediatric Center’s workforce.
For some disclosures, we may need your prior consent
or specific authorization. Below, we describe the
different categories of our uses and disclosures
and give you some examples of each category. |
| |
|
|
| |
A. |
Uses and Disclosures of Your Protected
Health Information for Treatment Purposes Do Not
Require Your Prior Written Consent. |
| |
|
We may use and disclose your protected
health information for the purpose of providing,
coordinating or managing your health care and related
services without obtaining your prior written consent.
This means that all healthcare personnel who are
involved in your care may have access to your protected
health information for these purposes. For example,
if your doctor refers you to a specialist for testing
and treatment, we can share your protected health
information with that specialist. |
| |
|
|
| |
B. |
Uses of Your
Protected Health information for Payment Purposes
Do Not Require Your Prior Written Consent. |
| |
|
We may use your protected health information
for the purpose of getting paid for the healthcare
services and items we provide to you. For example,
our billing, accounts receivable and collections
employees may access your protected health information
for this purpose. |
| |
|
|
| |
C. |
Disclosures of Your Protected Health
Information for Payment Purposes Require Your Prior
Written Consent. |
| |
|
North Carolina law requires us to
get your written consent to the disclosure of your
protected health information for payment purposes.
If you are an existing patient, you have already
signed a consent allowing us to share your protected
health information with your health insurance company
(or any other person or entity responsible for paying
for your healthcare services) for payment purposes.
If you are a new patient, you will be asked to sign
consent during your first visit with us. Other than
an emergency situation, we can refuse treatment
to any patient who does not sign a consent allowing
us to share protected health information with his
or her insurance company or any other person or
entity responsible for paying for your healthcare
services. For example, after obtaining your consent,
we may send your health insurance company a copy
of your physician’s notes to show that the tests
you received were medically necessary and thus should
be covered by the health insurance policy. |
| |
|
|
| |
D. |
Uses of Your Protected Health Information
for our Healthcare Operations Do Not Require Your
Prior Consent. |
| |
|
We may use your protected health information
in the operation of our practice for such purposes,
among others, as developing procedures and protocols,
reviewing the performance of your physician or other
healthcare providers, training new physicians and
other healthcare providers, business planning and
development, and general administrative activities
without your written consent. Note that this list
does not include every purpose for which we might
use your protected health information for our healthcare
operations. For example, our human resources section
may access your protected health information in
order to conduct a performance review of the nurse
who provides services to you at our office. |
| |
|
|
| |
E. |
Disclosures of Your Protected Health
Information for our Healthcare Operations Requires
Your Prior Written Consent. |
| |
|
North Carolina law requires us to
get your written consent to the disclosure of your
protected health information for our healthcare
operations. You will be asked to sign consent during
your first visit with us after January 1, 2003.
Other than emergency situation, we can refuse treatment
to any patient who does not sign a consent allowing
us to share protected health information for our
healthcare operations. For example, after obtaining
your consent, we may allow an independent consultant
to review your medical record as part of risk management
or billing compliance audit. |
| |
|
|
| |
F. |
Certain Other
Uses and Disclosures Do Not Require Your Prior Written
Consent. |
| |
|
Use and disclose your protected health
information without your consent or authorization
for the following reasons: |
| |
|
|
|
| |
|
I. |
When
disclosure is required by federal or local law,
judicial or administrative proceedings, or law enforcement.
|
| |
|
|
For example, we make disclosures of
protected health information when a law requires
us to report information to a government agency
or to law enforcement about victims of abuse or
neglect or gunshot or knife wounds, or when we receive
a valid court order to produce information. |
| |
|
|
|
| |
|
II. |
For public health activities to
avert a serious threat to health and safety. |
| |
|
|
For example, we report information
about certain diseases (such as West Nile virus
and Lyme disease) to the local health department;
we provide coroners, medical examiners and funeral
directors necessary information relating to an individual’s
death; and we may provide information to law enforcement
or another person if we believe, in good faith,
that the use or disclosure is necessary to prevent
serious and imminent threat to the health or safety
of a person or the public. |
| |
|
|
|
| |
|
III. |
For health oversight activities.
|
| |
|
|
For example, we may provide information
to the government when it investigates or inspects
our practice or another provider or facility. |
| |
|
|
|
| |
|
IV. |
For organ, eye
or tissue donation purposes. |
| |
|
|
For example, if you agree to participate
in a research study, we may provide your protected
health information to the person or entity conducting
the search. |
| |
|
|
|
| |
|
V. |
For certain research purposes.
|
| |
|
|
For example, if you agree to participate
in a research study, we may provide your protected
health information to the person or entity conducting
the search. |
| |
|
|
|
| |
|
VI. |
For specialized government functions. |
| |
|
|
For example, we may disclose protected
health information to authorized federal officials
for the conduct of lawful intelligence, counter
intelligence and other national security activities
authorized by law. |
| |
|
|
|
| |
|
VII. |
For worker’s compensation.
|
| |
|
|
For example, we disclose protected
health information related to your workman’s compensation
claim to your employer’s workers’ compensation insurance
carrier and to your employer who is paying us to
provide services to you in connection with the claim.
|
| |
|
|
|
| |
|
VIIL. |
Appointment Reminders and Health
Related Benefits or service. |
| |
|
|
We may use your protected health information
to provide appointment reminders to you or to give
you information about treatment alternatives or
other healthcare services we offer. |
| |
|
|
| |
G. |
Uses and Disclosures
Where You have the Opportunity to Object. |
| |
|
We may provide protected health information
to your family members, a friend or other person
that you indicated is involved in your care or the
payment of your health care, unless you object.
In emergency situations, you will have the opportunity
to object when you are able to do so. For example
if you have an appointment with one of our doctors
and you bring a family member with you and ask them
to sit in the examination room with you while the
doctor performs an examination then the doctor may
disclose protected health information to that family
member unless you object. Additionally, if you come
to our office alone and a physician decides to admit
you directly to the hospital, we may contact a family
member or friend to let them know that you have
been admitted to the hospital, unless you object.
|
| |
|
|
| |
H. |
Uses and Disclosures Require Your
Prior Written Authorization. |
| |
|
In any other situation not described
in sections II.a. above, we will ask for your written
authorization before using or disclosing your protected
health information. If you choose to sign an authorization
to disclose your protected health information, you
can later revoke that authorization in writing to
stop any future uses and disclosures (to the extent
we have not already taken action relying on your
authorization). |
| |
|
| III. |
YOUR HEALTH INFORMATION RIGHTS: |
| |
Although your health record is the
property of and belongs to Lakeshore Pediatric Center,
you have the following rights with respect to your
protected health information: |
| |
|
|
| |
A. |
The Right to Request Restrictions
on uses and Disclosures of Your Protected Health
Information. |
| |
|
You have the right to ask us to limit
how we use and disclose your protected health information.
We will consider your request, but we are not legally
required to accept it. If we do accept your request,
we will note the accepted limitations in writing
and follow those restrictions except in emergency
circumstances. You may not limit the uses and disclosures
that we are legally required to make. |
| |
|
|
| |
B. |
The Right to Choose How We Send
Protected Health Information. |
| |
|
You have the right to ask that we
send information to you to an alternate address
(for example, sending information to your home address
instead of your work address) or by alternate means
(for example, by e-mail instead of regular mail).
If we can easily provide the information in the
format you request, then we must agree to your request
and abide by it. |
| |
|
|
| |
C. |
The Right to See and Get Copies
of Your Protected health Information. |
| |
|
In most cases you have the right to
look at or get copies of your protected health information.
You must make any request to look at or get copies
of your protected health information in writing
to the contact person identified in section V. below.
We will respond to you within 30 days after receiving
your written request. In certain situations, we
may deny your request. If we deny your request,
we must tell you, in writing our reasons for denying
your request and explain to you that you have the
right to have our decision reviewed and how to start
the review process. If you request copies of your
protected health information, we will charge $ for
each page. Instead of providing the information,
we may provide you with a summary or explanation
and to pay the cost for it in advance. |
| |
|
| IV. |
HOW TO COMPLAIN ABOUT OUR PRIVACY
PRACTICES: |
| |
If you think we have violated your
privacy rights or you disagree with a decision we
made about access to your protected health information,
you may file a complaint with the person listed
in Section V. below. You may also send a written
complaint to the Secretary of the United States
Department of Health and Human Services, 200 Independent
Avenue, S.W., Washington DC, 20201. No adverse action
will be taken by us against you for filing a complaint. |
| |
|
| V. |
PERSON TO CONTACT FOR INFORMATION
ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY
PRACTICES: |
| |
If you have any questions
about this Notice or have any complaints about
our privacy practices, or would like assistance,
including the appropriate forms to use, in exercising
ANY OF THE RIGHTS LISTED IN section III. Above
or would like to know how to file a complaint
with the Secretary of the United States Department
of Health and Human Services, please contact |
| |
|
James Ramsey
P.O. Box 677
Lincolnton, NC 28093 |
| |
|
| VI. |
EFFECTIVE DATE OF THIS NOTICE: |
| |
This Notice is
effective April 14, 2003. |
