THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TOTHIS INFORMATION, PLEASE REVIEW CAREFULLY.
Uses and Disclosures:
Treatment – Your health information may be used by staff members or disclosed to other health professionals for the purpose
of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical records to all health professionals who may provide treatments or who may be consulted by staff members.
Payment – Your health information may be used to seek payment from your health plan,from other sources of coverage such as automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of services, the services provided, and the medical condition being treated.
Health Care Operations – Your health information may be used as necessary to support the day-to-day activities and management of Cape Fear Otolaryngology, PA. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law Enforcement – Your health information may be disclosed to public health agencies, without permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public Health Reporting – Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other Uses and Disclosures (Require Your Authorization):
Disclosure of your health information or its use of any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use of disclosure or information that occurred before you notified us of your decision.
Additional Use of Information (Require Your Authorization):
Appointment Reminders – Your health information will be used by our staff to send you appointment reminders. We will also contact you by phone to remind you of your upcoming appointment. Our policy regarding a reminder call that is answered by voicemail or machine, we will leave a message stating the name of our office, our telephone number and the date and time of the upcoming appointment.
Information About Treatments- Your health information may be used to send you information on the treatment and management of your medical condition that you may find out of interest. We may also send you information describing other health-related goods and services that we may believe may interest you.
You have certain rights under federal privacy standards. These include:
- The right to request restrictions on the use and disclosure of your protected health information.
- The right to receive confidential communication concerning your medical condition and treatment.
- The right to inspect and copy your protected health information.
- The right to amend or submit corrections to your protected health information.
- The right to receive an accounting of how and to whom your protected health information has been disclosed.
- The right to receive a printed copy of this notice.
Cape Fear Otolaryngology, PA Duties:
We are required to abide by privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices:
As permitted by law we reserve the right to amend or modify our privacy practices or policies. These changes in our policies and practices may be required by changes in federal and state law/regulations. Whatever the reason for these revisions, we will provide you with a revised policy upon your next office visit. The revised practices and policies will be applied to all protected health information.
As permitted by federal regulations, we require that requests to inspect a copy of your protected health information be submitted in writing. To get copies of your records or to request that they be sent to another party, you may obtain a records release form from our staff at the front desk. Once this signed authorization has been received, we reserve the right to allow our office personnel to copy your records and send them to the requesting party within 7 business days.
Contacts for More Information and/or Complaints:
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to the contact listed below:
Cape Fear Otolaryngology, PA 2053 Valleygate Drive, Suite 101
Fayetteville, NC 28304 Attn: Practice Administrator
If you believe your privacy rights have been violated, you should call attention to the matter by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
This notice is effective on and after January 1, 2003.
Consent to Disclosure of Protected Health Information Notice of Privacy Practices:
You should review the Notice of Privacy Practices above for a complete description of how your protected health information may be used or disclosed. Please review the notice prior to signing this consent.
Requesting a Restriction on the Use or Disclosure of Your Information:
You may request a restriction on the use or disclose of your protected health information.
Cape Fear Otolaryngology may or may not agree to restrict the use of disclosure of your protected health If Cape Fear Otolaryngology agrees to your request, the restriction will be binding on the practice. Use of
disdosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Revocation of Consent:
You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has occurred prior to the date on which your revocation of consent is received will not be affected.
Reservation of Rights to Change Privacy Practices:
Cape Fear Otolaryngology reserves the right to modify the privacy practices outlined in this notice.