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.
If you have any questions about this Notice of Privacy Practices, please contact our Privacy
Officer, by telephone at (704) 824-7800 or in writing at 2675 Court Drive, Gastonia, NC
This Notice of Privacy Practices describes how we may use and disclose your protected
health information to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your rights to access and
control your protected health information. Protected health information is information about
you, including demographic information, that may identify you and that relates to your past,
present or future physical or mental health or condition and related health care services.
A. WE MUST PROTECT YOUR PROTECTED HEALTH INFORMATION
We are required to abide by the terms of this Notice of Privacy Practices. We may change the
terms of our Notice of Privacy Practices at any time. The new Notice of Privacy Practices will
be effective for all protected health information that we maintain at that time. Upon your
request, we will provide you with any revised Notice of Privacy Practices. You may request a
revised version by calling or writing our Privacy Officer and requesting that a revised copy be
sent to you in the mail or asking for one at the time of your next appointment.
B. USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by our office staff others outside of
our office who are involved in your care and treatment for the purpose of providing health care
services to you.
Your protected health information may also be used and disclosed to pay
your health care bills and to support the operation of our practice.
Following are examples
of the types of uses and disclosures of your protected health information that we are permitted
to make. These examples are not meant to be exhaustive, but to describe the types of uses and
disclosures that may be made by our office.
1. Treatment: We will
use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care
with another provider.
For example, we would disclose your protected health information, as
necessary, to a home health agency that provides care to you. We will also disclose protected
health information to other healthcare providers who may be treating you.
For example, your
protected health information may be provided to a physician to whom you have been referred to
ensure that the physician has the necessary information to diagnose or treat you. In addition,
we may disclose your protected health information from time-to-time to other health care
providers (e.g., a specialist or laboratory) who become involved in your care by providing
assistance with your health care diagnosis or treatment to us.
2. Payment: We may use
and disclose protected health information about you so that the treatment and services you
receive at Hot Springs Sports Medicine may be billed to and payment may be collected from you,
an insurance company, or a third party. This may include certain activities that your health
insurance plan 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 reviewing services provided to you for medical necessity. For example, if you have
a back injury, we may need to give your health plan information about your condition, supplies
used, and services you received.
Operations: We may use or disclose, as needed, your protected health
information for healthcare operations. These uses and disclosures are necessary to run Hot
Springs Sports Medicine and make sure that all of our patients receive quality care. For
example, we ma)'use protected health information to review our treatment and services and to
evaluate the performance of our staff in caring for you. We may also combine protected health
information about many patients to decide what additional services Hot Springs Sports Medicine
should offer, what services are not needed, and whether certain new treatments are effective. We
may also disclose information to doctors, nurses, technicians, medical students, and other
personnel for review and learning purposes, we may remove information that identifies you from
this set of protected health information so others may use it to study health care and health
care delivery without learning the identities of specific patients.
We may share your
protected health information with third party "business associates" that perform various
activities (for example, billing or transcription services) for our practice. Whenever an
arrangement between our practice and a business associate involves the use or disclosure of your
protected health information, we will have a written contract that contains terms that will
protect the privacy of your protected health information.
We may use and / or disclose
protected health information to contact you to, remind you about an appointment you have for
treatment or medical care.
We may use or disclose your protected health information, as
necessary, to provide you with information about treatment alternatives or other health--related
benefits and services that may be of interest to you. You may contact our Privacy Officer to
request that these materials not be sent to you.
4. Other Permitted and Required Uses
and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree and
We may use or disclose your protected health information in
the following situations without your authorization or providing you the opportunity to agree or
object. These situations include:
(i) Required by Law: We may use or disclose your protected health information to the extent
that the use or disclosure is required by law. The use or disclosure will be made in compliance
with the law and will be limited d to the relevant requirements of the law. You will be
notified, if required by law, of any such uses or disclosures.
(ii) Public Health: We may disclose your protected health information for public health
activities and purposes to a public health authority that is permitted by law to collect or
receive the information. For example, a disclosure may be made for the purpose of preventing or
controlling disease, injury or disability.
(iii) Communicable Diseases: We may disclose
your protected health information, if authorized by law, to a person who may have been exposed
to a communicable disease or may otherwise be at risk of contracting or spreading the disease or
Oversight: We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections. Oversight
agencies seeking this information include government agencies t-rat oversee the health care
system, government benefit programs, other government regulatory programs and civil rights
(v) Abuse or
Neglect: We may disclose your protected health information to a public health authority
that is authorized by law to receive reports of child abuse or neglect. In addition, we may
disclose your protected health information if we believe that you have been a victim of abuse,
neglect or domestic violence to the governmental entity or agency authorized to receive such
information. In this case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
(vi) Legal Proceedings: We may
disclose protected health information in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative tribunal (to the extent such
disclosure is expressly authorized), or in certain conditions in response to a subpoena,
discovery request or other lawful process.
(vii) Law Enforcement: We may also
disclose protected health information, so long as applicable legal requirements are met, for law
enforcement purposes, these law enforcement purposes include (1) legal processes and otherwise
required by law, (2) limited information requests for identification and location purposes, (3)
pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal
conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical
emergency (not on our premises) and it is likely that a crime has occurred.
(viii) Research: We may disclose your
protected health information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and established protocols to
ensure the privacy of your protected health information.
(ix) Criminal Activity: Consistent
with applicable federal and state laws, we may disclose your protected health information, if we
believe that the use or disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to identify or apprehend an
Activity and National Security: When the appropriate conditions apply, we may use or
disclose protected health information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities; (2) for the purpose of
a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3)
to foreign military authority if you are a member of that foreign military services. We may also
disclose your protected health information to authorized federal officials for conducting
national security and intelligence activities, including for the provision of protective
services to the President or others legally authorized.
(xi) Workers' Compensation: We may
disclose your protected health information as authorized to comply with workers' compensation
laws and other similar legally established programs.
5. Other Permitted and Required Uses
of Disclosures That Require Providing You the Opportunity to Agree or
We may use and disclose your protected health information in
the following instances. You have the opportunity to agree or object to the use or disclosure of
all or part of your protected health information. If you are not present or able to agree or
object to the use or disclosure of the protected health information, then we may, using
professional judgment, determine whether the disclosure is in your best interest.
Others Involved in Your Health Care or Payment for our
Unless you object, we may disclose to a member of your family, a relative, a close friend or any
other person you identify, your protected health information that directly relates to that
person's involvement in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your
best interest based on our professional judgment. We may use or disclose protected health
information to notify or assist in notifying a family member, personal representative or any
other person that is responsible for your care of your location, general condition or death.
Finally, we may use or disclose your protected health information to an authorized public or
private entity to assist in disaster relief efforts and to coordinate uses and disclosures to
family or other individuals involved in your health care.
6. Uses and Disclosures of
Protected Health Information Based upon Your Written Authorization Other
uses and disclosures of your protected health information will be made only with your written
authorization, unless otherwise permitted or required by law as described below. You may revoke
this authorization in writing at any time. If you revoke your authorization, we will no longer
use or disclose your protected health information for the reasons covered by your written
authorization. Please understand that we are unable to take back any disclosures already made
with your authorization.
Following is a statement of your rights with respect to your
protected health information and a brief description of how you may exercise these rights
1. You have the right to
inspect and copy your protected health information
This means you may
inspect and obtain a copy of protected health information about you for so long as we maintain
the protected health information. You may obtain your medical record that contains medical and
billing records and any other records that we use for making decisions about you. As permitted
by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
2. You have the right to
request a restriction of your protected health information
you may ask us not to use or disclose any part of your protected health information for the
purposes of treatment, payment or health care operations. You may also request that any part of
your protected health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice of Privacy
Practices. Your request must state the specific restriction requested and to whom you want the
restriction to apply.
We are not required to agree to a restriction that you may
request. If we agree to the requested restriction, we may not use or disclose your protected
health information in violation of that restriction unless it is needed to provide emergency
treatment. With this in mind, please discuss any restriction you wish to request with your
You may request a restriction by making your request in writing to our
Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2)
whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to
apply, for example, disclosures to your spouse.
3. You have the right to
request to receive confidential communications from us by alternative means or at an
We will accommodate reasonable requests. We may
also condition this accommodation by asking you for information as to how payment will be
handled or specification of an alternative address or other method of contact. We will not
request an explanation from you as to the basis for the request. Please make this request in
writing to our Privacy Officer.
4. Your may have right to
amend your protected health information
This means you may request an amendment of protected health information
about you in a designated record set for so long as we maintain this information. In certain
cases, we may deny your request for an amendment. If we deny your request for amendment, 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. Please contact our Privacy
Officer if you have questions about amending your medical record.
5. You have the right to
receive an accounting of certain disclosures we have made, if any, of your protected
This right applies to disclosures for purposes other than treatment, payment
or health care operations as described in this Notice of Privacy Practices. It excludes
disclosures we may have made to you if you authorized us to make the disclosure, to family
members or friends involved in your care, or for notification purposes, for national security or
intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities,
as part of a limited data set disclosure. The right to receive this information is subject to
certain exceptions, restrictions and limitations.
6. You have the right to
obtain a paper copy of this notice from us
upon request, even if you
have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and
Human Services if you believe your privacy rights have been violated by us. You may file a
complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate
against you for filing a complaint
You may contact our Privacy Officer at (704) 824-7800
for further information about the complaint process.
This notice was published and
becomes effective on August l, 2011.