Notice of Privacy Practices





Effective Date: 10/15/2021
This Notice was revised on 10/15/2021.

About This Notice

We are required by law to maintain the privacy of protected health information (“PHI”) and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your PHI, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.

What is PHI?

“PHI” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.

Your Rights Under the Federal Privacy Standard

You have the following rights, subject to certain limitations, regarding your PHI:

Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request to the extent permitted by law. We may deny your request in certain limited circumstances. If we deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will try to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If not, your record will be provided in our standard electronic format, or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Request Amendments. If you feel that the PHI we have is incorrect or incomplete, you may ask us to amend the information. A request for amendment must give us the reason for your request. We may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of certain disclosures we made of your PHI. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full.

Out-of-Pocket-Payments. If you paid out-of-pocket in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.

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

How to Exercise Your Rights

To exercise your rights described in this Notice, send your request, in writing, to our Privacy Contact Person at the address listed in this Notice. We may ask you to fill out a form that we will supply. To get a paper copy of this Notice, contact our Privacy Contact Person by phone or mail.

Changes To This Notice

We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our website.

How to Get More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact our Privacy Contact Person at (704) 553-3815. If you believe that your privacy rights have been violated, you may complain to our Privacy Contact Person in writing at:

The Sharon at SouthPark
5100 Sharon Road
Charlotte, NC 28210
ATTN: Privacy Contact Person

You may also report complaints with the Office for Civil Rights of the U.S. Health and Human Services. No retaliation will be taken against an individual who files a complaint.

How We May Use and Disclose Your PHI

We may use and disclose your PHI in the following circumstances:

For Treatment. We may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, your PHI may be provided to a physician or other provider (e.g., a laboratory) to whom you have been referred to ensure that the physician or other provider has the necessary information to treat you or provide you with a service.

For Payment. We may use and disclose your PHI so that we can bill and collect for the treatment and services you receive from us. This use and disclosure may include certain activities that your payor may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, and undertaking utilization review activities.

For Health Care Operations. We may use and disclose PHI for our health care operations. For example, members of our nursing staff and our quality assurance team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers.

Business associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing. To protect your PHI, however, we require the business associate to appropriately safeguard it.

Research. We may disclose PHI to researchers when their research have been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of PHI or in certain other limited situations.

Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to a coroner, medical examiner or funeral director consistent with applicable law to enable them to carry out their duties.

Treatment Alternatives/ Health-Related Benefits and Services. We may contact you to provide information about treatment alternatives or other health-related benefits and services that may interest you.

As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others as permitted by applicable law.

Workers Compensation. We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Military and Veterans. If you are a member of the armed forces, we may disclose PHI as required by military command authorities or to the appropriate foreign military authority if you are a member of a foreign military.

Public Health Risks. We may disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report deaths; (4) report reactions to medications or problems with products; and (5) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Abuse, Neglect, or Domestic Violence. We may disclose PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.

Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include audits, inspections, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your PHI.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit.

Law Enforcement. We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.

Organ/Cadaver Procurement Organizations. We may disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadavers, cadaveric organs, eyes, or tissues for the purpose of facilitation organ, eye or tissue donation and transplantation in accordance with your request and agreement.

Uses and Disclosures that Require Us to Give You an Opportunity to Object and Opt Out

Directory. Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who may ask for your name.

Disaster. In the event of a disaster, we may release PHI to a public or private entity to assist in disaster relief efforts. We will provide you with an opportunity to object to such disclosure whenever we practicably can do so.

Communication with Family. Unless you object, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, PHI relevant to that person’s involvement in your care or payment related to your care.

Fundraising Activities. We may use or disclose your PHI, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications.

Other Uses and Disclosures

The following uses and disclosures or your PHI will be made only with your written authorization: most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes and disclosures that constitute a sale of your PHI. Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Contact Person and we will no longer disclose PHI under the authorization. However, disclosures that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

Additional Rights under North Carolina and Other Federal Laws

If another North Carolina or federal law requires us to give more protection to your PHI than stated in this Notice, we will comply with that law.

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