NOTICE OF PRIVACY PRACTICES OF NASH HEALTH CARE SYSTEMS
Which Includes: Nash General Hospital Nash Day Hospital Coastal Plain Hospital Bryant T. Aldridge Rehabilitation Center Nash Urgent Care Nash Community Health Services Family Counseling Services & Various Physician Groups Identified in Appendix A
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.
Effective: April 14, 2003
If you have any questions or requests, please contact NHCS's Health Information Management Department at 443-8130.
A. WHO WILL FOLLOW THIS NOTICE
Nash Health Care Systems is comprised of Nash General Hospital, Nash Day Hospital, Coastal Plain Hospital, Bryant T. Aldridge Rehabilitation Center, Nash Urgent Care, Family Counseling Services and Nash Community Health Services. Additionally, and for the purposes of this Notice, NHCS and various physician groups identified in Appendix A have agreed to participate in an Organized Health Care Arrangement. All these entities, sites and locations follow the terms of this Notice, and we refer to them individually or collectively, as the context requires, as NHCS. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this Notice.
B. OUR PLEDGE REGARDING HEALTH INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at NHCS. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by NHCS, whether made by NHCS personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.
C. WE HAVE A LEGAL DUTY TO PROTECT HEALTH INFORMATION ABOUT YOU
This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required to protect the privacy of medical information about you and that can be identified with you, which we call protected health information, or PHI for short. We must give you notice of our legal duties and privacy practices concerning PHI:
We must protect PHI that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care.
We must notify you about how we protect PHI about you.
We must explain how, when and why we use and/or disclose PHI about you.
We may only use and/or disclose PHI as we have described in this Notice.
This Notice describes the types of uses and disclosures of your PHI that we may make and gives you some examples. In addition, we may make other uses and disclosures of your PHI that occur as a byproduct of the permitted uses and disclosures described in this Notice.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:
Posting the revised Notice in our offices;
Making copies of the revised Notice available upon request (either at our offices or through the contact person listed in this Notice); and
Posting the revised Notice on our website.
D. WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES
1. We may use and disclose PHI about you to provide health care treatment to you.
We may use PHI about you to provide you with medical treatment or services. We may disclose PHI about you to doctors, nurses, technicians, medical students, or other NHCS personnel who are involved in taking care of you at NHCS. Different departments of NHCS also may share PHI about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
EXAMPLE: A doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals.
2. We may use and disclose PHI about you to obtain payment for services.
Generally, we may use and disclose PHI about you so that the treatment and services you receive at NHCS may be billed to and payment may be collected from you. We may also share portions of your PHI with the following:
NHCS collection departments or outside agencies;
NHCS departments that review the care you received to check that it and the costs associated with it were appropriate for your illness or injury; and
Consumer reporting agencies (e.g., credit bureaus).
EXAMPLE: Let's say you have a broken leg. We need to give information about your condition, supplies used (such as plaster for your cast or crutches), and services you received (such as x-rays or surgery) to our billing department so we can be paid. We may also send the same information to our hospital department that reviews our care of your illness or injury.
3. We may use and disclose your PHI for health care operations.
We may use and disclose PHI in performing business activities, which we call health care operations. These health care operations allow us to improve the quality of care we provide and reduce health care costs. Examples of the way we may use or disclose PHI about you for health care operations include the following:
Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided 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, for instance, about treatment alternatives, classes, or new procedures.
Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
Providing training programs for students, trainees, health care providers or non-health care professionals (for example, billing clerks or assistants, etc.) to help them practice or improve their skills.
Cooperating with outside organizations that assess the quality of the care we and others provide. These organizations might include government agencies or accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations.
Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty. For example, we may use or disclose PHI so that one of our nurses may become certified as having expertise in a specific field of nursing, such as pediatric nursing.
Assisting various 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 assist us in complying with applicable laws.
Planning for our organization's future operations, and fundraising for the benefit of our organization.
Conducting business management and general administrative activities related to our organization and the services it provides, including providing information.
Resolving grievances within our organization.
Reviewing activities and using or disclosing PHI in the event that we sell our business, property or give control of our business or property to someone else.
Complying with this Notice and with applicable laws.
4. We may use and disclose PHI under other circumstances without your authorization.
We may use and/or disclose PHI about you for a number of other circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:
When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
When the use and/or disclosure is necessary for public health activities. For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
When the disclosure relates to certain victims of abuse, neglect or domestic violence.
When the use and/or disclosure is for health oversight activities. For example, we may disclose PHI about you to a state or federal health oversight agency which is authorized by law to oversee our operations.
When the disclosure is for judicial and administrative proceedings. For example, we may disclose PHI about you in response to a subpoena or order of a court or administrative tribunal.
When the disclosure is for law enforcement purposes. For example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
When the use and/or disclosure relates to decedents. For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
When the use and/or disclosure relates to medical research. Under certain circumstances, we may disclose PHI about you for medical research.
When the use and/or disclosure is to avert a serious threat to health or safety. For example, we may disclose PHI about you to North Carolina Secretary of Health and Human Services to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.
When the use and/or disclosure relates to specialized government functions. For example, we may disclose PHI about you if it relates to military and veterans activities, national security and intelligence activities, protective services for the President, and medical suitability or determinations of the Department of State.
When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, we may disclose PHI about you to a correctional institution having lawful custody of you.
5. We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
6. 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 healthcare. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value.
EXAMPLE: If you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
7. We may contact you for fundraising activities.
We may use and/or disclose PHI about you, including disclosure to our foundation, to contact you to raise money for NHCS and its operations. We would only release contact information and the dates you received treatment or services at NHCS. If you do not want to be contacted in this way, you must notify in writing our contact person listed on the cover page of this Notice.
8. You can object to certain uses and disclosures.
Unless you object, we may use or disclose PHI about you in the following circumstances:
Hospital Directory. We may include certain limited information about you in NHCS directory while you are a patient at NHCS. This information may include your name, location in NHCS, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don¡¦t ask for you by name. This is so your family, friends and clergy can visit you in NHCS and generally know how you are doing.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in NHCS.
Disaster Relief Purposes. We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances.
If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call our contact person listed on the cover page of this Notice.
ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES YOUR WRITTEN AUTHORIZATION **
Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. 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. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.
E. YOU HAVE SEVERAL RIGHTS REGARDING PHI ABOUT YOU
1. You have the right to request restrictions on uses and disclosures of PHI about you.
You have the right to request that we restrict the use and disclosure of PHI about you for treatment, payment or health care operations. We are not required to agree to your requested restrictions. However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection 4 of the previous section of this Notice.
To request restrictions, you must make your request in writing to the NHCS Health Information Management Department. 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.
2. You have the right to request different ways to communicate with you.
You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by contacting the NHCS Health Information Management Department.
3. You have the right to see and copy PHI about you.
You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the NHCS Health Information Management Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.
4. You have the right to request amendment of PHI about you.
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for NHCS.
To request an amendment, your request must be made in writing and submitted to the NHCS Health Information Management Department. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by or for NHCS;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will notify you and make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.
5. You have the right to an accounting of disclosures we have made.
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the NHCS Health Information Management Department. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically).
We are required to provide a listing of all disclosures except the following:
For your treatment
For billing and collection of payment for your treatment
For our health care operations
Made to or requested by you, or that you authorized Occurring as a byproduct of permitted uses and disclosures
Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in subsection D.8 above
Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.4 above) and
As part of a limited set of information which does not contain certain information which would identify you
The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.
If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee.
6. You have the right to a copy of this Notice.
You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
You may obtain a copy of this Notice at our website, www.nhcs.org.
To obtain a paper copy of this Notice, contact the NHCS Health Information Management Department at (252) 443-8130.
F. CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in NHCS, and we will give to you a copy of any revised version of this Notice upon the next provision of services to you after such change.
G. YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you think your privacy rights have been violated by us, or you want to complain to us about our privacy practices, you can contact the person listed below:
Nash Health Care Systems Compliance Officer
2460 Curtis Ellis Drive
Rocky Mount, North Carolina 27804
Phone Number: 443-8015
E-mail: jeparsons@nhcs.org
You may also send a written complaint 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.
H. EFFECTIVE DATE OF THIS NOTICE
This Notice of Privacy Practices is effective on April 14, 2003.
APPENDIX A
Physician Group
Southeastern Acute Care Specialists, P.A. / Nash General Hospital Emergency Care Center
Robert E. Zipf, Jr., M.D., P.A. / Nash General and Nash Day Hospitals Pathology Department
Nash X-Ray Associates, P.A. / Nash General and Nash Day Hospitals Radiology Department
Nash Anesthesia Associates, P.A. /Nash General and Nash Day Hospitals Operating Rooms
North Carolina Inpatient Medicine /Nash General Hospital Associates, P.A.
Carolina Rehabilitation & Surgical Associates, PA /Bryant T. Aldridge Rehabilitation Center
Boice-Willis Clinic, P.A /910 North Winstead Avenue / Rocky Mount, North Carolina
Boice-Willis Primary Care
100 Nash Medical Arts Mall / Rocky Mount, North Carolina
Internal Medicine Center / 1051 Country Club Drive / Rocky Mount, North Carolina /
111 West Church Street / Nashville, North Carolina
100 Dodd Street / Spring Hope, North Carolina