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 Date: 09/23/2013
If you have any questions
about this notice, please contact the Gastonia Medical Specialty Clinic PA
Privacy Officer at (704) 867-2341.
WHO WILL FOLLOW THIS NOTICE
This notice describes the
Gastonia Medical Specialty Clinic PA.
Any health care professional authorized to enter information into your
medical record maintained by Gastonia Medical Specialty Clinic PA .
Any persons or companies with whom Gastonia Medical Specialty Clinic PA
contracts for services to help operate our practice and who have access to your
All these persons, entities, sites, and locations follow the terms of
this notice. In addition, these persons,
entities, sites, and locations may share medical information with each other
for treatment, payment, or health care operations purposes and other purposes
described in this notice.
PLEDGE REGARDING MEDICAL 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 from Gastonia Medical Specialty
Clinic PA. 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 and billing for
that care that are generated or maintained by Gastonia Medical Specialty Clinic PA, whether made by Gastonia Medical Specialty Clinic PA personnel or other health care providers. Other health care providers may have
different policies or notices about confidentiality and disclosure that apply
to your medical information that is created in their offices or at locations
other than Gastonia
Medical Specialty Clinic PA .
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
your medical information.
We are required by law to:
Make sure that
medical information that identifies you is kept private;
Give you this
notice of our legal duties and privacy practices at Gastonia Medical Specialty
Clinic PA, and your legal rights, with
respect to medical information about you; and
Follow the terms
of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU
The following categories describe different ways that
we use and disclose medical information.
For each category of uses or disclosures we will explain what we mean
and try to give some examples. Not every
use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose
information will fall within one of these categories.
For Treatment. We may use medical information
about you to provide you with medical treatment or services. We may disclose medical information about you
to doctors, nurses, technicians, medical students, volunteers, or other
personnel who are involved in taking care of you at Gastonia Medical Specialty
Clinic PA. For example, a doctor treating you for a
broken hip may need to know if you have diabetes because diabetes may slow the
healing process. We also may disclose
medical information about you to people outside Gastonia Medical Specialty Clinic PA who may be involved in your medical care after you
have been treated by Gastonia Medical Specialty Clinic PA,
such as friends, family members, or employees or medical staff members of any
hospital or skilled nursing facility to which you are transferred or
For Payment. We may use and disclose medical information
about you so that the treatment and services you receive from Gastonia Medical Specialty
may be billed by Gastonia Medical Specialty Clinic PA
and payment may be collected from you, an insurance company, or a third
party. For example, we may need to give
your health plan information about treatment you received from Gastonia Medical Specialty
Clinic PA so your health plan will pay us
or reimburse you for the treatment. We
also may disclose information about you to another health care provider, such
as a hospital or skilled nursing facility to which you are admitted, for their
payment activities concerning you.
For Health Care Operations. We and our
business associates may use and disclose medical information about you for
health care operations. These uses and
disclosures are necessary to run Gastonia Medical Specialty Clinic PA and make sure that all of our patients receive
quality care. For example, we may use
medical information to review our treatment and services and to evaluate the
performance of our staff in caring for you.
We may also combine medical information about many patients to decide
what additional services Gastonia Medical Specialty Clinic PA
should offer, and what services are not needed.
We may also disclose information to doctors, nurses, technicians, and
other personnel affiliated with Gastonia Medical Specialty Clinic PA for review and learning purposes. We may also combine the medical information
we have with medical information from other health care providers to compare
how we are doing and see where we can make improvements in the care and
services we offer. We may remove
information that identifies you from this set of medical information so others
may use it to study health care and health care delivery without learning the
identities of specific patients. We also
may disclose information about you to another health care provider for its health
care operations purposes if you also have received care from that provider.
Treatment Alternatives. We may use
and disclose medical information to tell you about or recommend different ways
to treat you.
Fundraising Activities. We may use
medical information about you to contact you in an effort to raise money for Gastonia Medical Specialty
Clinic PA and its operations. Specifically, we may use information about
you to target our fundraising efforts.
For example, if we are raising money for women’s health services, we may
focus our fundraising efforts on individuals who have received women’s health
services from us in the past. We may also disclose medical information to a
business partner or a foundation related to Gastonia Medical Specialty Clinic PA so that the business partner or the foundation may
contact you in raising money for Gastonia Medical Specialty Clinic PA . We would
release limited information about you, such as your name, address and phone
number, age and date of birth, gender, your physician, and the dates you
received treatment or services at Gastonia Medical Specialty Clinic PA.
If you do not want Gastonia Medical Specialty
Clinic PA to contact you for fundraising
efforts, you must notify Gastonia Medical Specialty Clinic PA’s Privacy Officer in writing. If you have not already done so, we must ask you each
time we contact you for fundraising efforts if you wish to opt out of all
future fundraising communications. If
you do opt out of future fundraising communications, we will no longer disclose
your information for fundraising purposes.
However, in the future you may let us know in writing that you would
like to receive these fundraising communications. Your decision whether or not to receive
targeted fundraising materials from us will have no impact on your access to
health care services or the treatment we provide to you.
Even if you have opted-out, we
may send you non-targeted fundraising materials that are sent out to the
general community and are not based on information from your treatment.
Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes. For example, a research project may involve
comparing the health and recovery of all patients who received one medication
to those who received another for the same condition. Medical information about you that has had
identifying information removed may be used for research without your
consent. We also may disclose medical
information about you to people preparing to conduct a research project (for
example, to help them look for patients with specific medical needs), so long
as the medical information they review does not leave Gastonia Medical Specialty
Clinic PA. If the researcher will have information about
your mental health treatment that reveals who you are, we will seek your
consent before disclosing that information to the researcher. Unless we notify you in advance and you give
us written permission, we will not receive any money or
other thing of value in connection for using or disclosing your medical
information for research purposes except for money to cover the costs of
preparing and sending the medical information to the researcher.
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. This would include persons named in any
durable health care power of attorney or similar document provided to us. We may also give information to someone who
helps pay for some or all of your care.
In addition, we may disclose medical information about you to an entity
assisting in a disaster relief effort so that your family can be notified about
your condition, status, and location.
You can object to these releases by telling us that you do not wish any
or all individuals involved in your care to receive this information. If you are not present or cannot agree or
object, we will use our professional judgment to decide whether it is in your
best interest to release relevant information to someone who is involved in
your care or to an entity assisting in a disaster relief effort.
As Required or Permitted By Law. We may disclose
medical information about you when required or permitted to do so by federal,
state, or local law.
To Avert a Serious Threat to Health or Safety. We
may use and disclose medical information about you when it appears necessary to
prevent a serious threat to your health and safety or the health and safety of
the public or another person. Any
disclosure would be to someone who appears able to help prevent the threat and
will be limited to the information needed.
Organ and Tissue Donation. If you are an
organ donor, we may release medical information to organizations that handle
organ procurement or organ, eye, or tissue transplantation, or to an organ
donation bank as necessary to facilitate organ or tissue donation and
Active Duty Military Personnel and Veterans. If you are an
active duty member of the armed forces or Coast Guard, we must give certain information
about you to your commanding officer or other command authority so that your
fitness for duty or for a particular mission may be determined. We may also release medical information about
foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the
Department of Veterans Affairs medical information about you to determine
whether you are eligible for certain benefits.
Workers’ Compensation. In accordance
with state law, we may release without your consent medical information about
your treatment for a work-related injury or illness or for which you claim
workers’ compensation to your employer, insurer, or care manager paying for
that treatment under a workers’ compensation
program that provides benefits for work-related injuries or illness.
Public Health Risks. We may disclose without your consent medical
information about you for public health activities. These activities generally include but are
not limited to the following:
To report, prevent
or control disease, injury, or disability;
To report births
reactions to medications or problems with products;
To notify people
of recalls of products they may be using;
To notify a
person who may have been exposed to a disease or may be at risk for contracting
or spreading a disease or condition; and
suspected abuse or neglect as required by law.
Health Oversight Activities. We may
disclose without your consent medical information to a health oversight agency
for activities authorized by law. These
oversight activities include, for example, audits, investigations, inspections,
and licensure. The government uses these
activities to monitor the health care system, government programs, and
compliance with civil rights laws.
Lawsuits and Disputes. If you are
involved in a lawsuit or a dispute, we must disclose medical information about
you in response to a court or administrative order. We also may disclose medical information
about you in response to a subpoena or other lawful process from someone
involved in a civil dispute.
Law Enforcement. We may release without your
consent medical information to a law enforcement official:
In response to a
court order, warrant, summons, grand jury demand, or similar process;
To comply with
mandatory reporting requirements for violent injuries, such as gunshot wounds,
stab wounds, and poisonings;
In response to a
request from law enforcement for certain information to help locate a fugitive,
material witness, suspect, or missing person;
To report a death
or injury we believe may be the result of criminal conduct; and
suspected criminal conduct committed at Gastonia Medical Specialty Clinic PA facilities.
Coroners and Medical Examiners. We may
release without your consent medical information to a coroner or medical
examiner. This may be done, for example,
to identify a deceased person or determine the cause of death. We also may release medical information about
deceased patients of Gastonia Medical Specialty Clinic PA
to funeral directors to carry out their duties.
National Security and Intelligence Activities. We may
release without your consent medical information about you as required by
applicable law to authorized federal or state officials for intelligence,
counterintelligence, or other governmental activities prescribed by law to
protect our national security.
Protective Services for the President and Others. We
may disclose medical information about you to authorized federal officials so
they may provide protection to the President, other authorized persons, or
foreign heads of state, or to conduct special investigations.
Psychotherapy Notes. Regardless of the other parts of this Notice,
psychotherapy notes will not be disclosed outside the Gastonia Medical Specialty
Clinic PA except as authorized by you in writing or
pursuant to a court order, or as required by law. Psychotherapy notes about you will not be
disclosed to personnel working within Gastonia Medical Specialty Clinic PA , except for training purposes or to defend a legal
action brought against Gastonia Medical Specialty Clinic PA, unless you have properly authorized such disclosure in writing.
Marketing of Health-Related Products and Services. “Marketing”
means a communication for which we receive any sort of payment from a third
party that encourages you to use a service or buy a product. Before we may use or disclose your medical
information to market a health-related product or service to you, we must
obtain your written authorization to do so.
The authorization form will let you know that we have been paid to make
the communication to you. Marketing does
not include: prescription refill
reminders or other information that describes a drug you currently are being prescribed,
so long as any payment we receive for that communication is to cover the cost
of making the communication; face-to-face communications; or gifts of nominal
value, such as pens or key chains stamped with our name or the name of a health
care product manufacturer. Communications
made about your treatment, such as when your physician refers you to another
health care provider, generally are not marketing.
Sale of Medical Information. We
cannot sell your medical information without first receiving your authorization
in writing. Any authorization form you
sign agreeing to the sale of your medical information must state that we will
receive payment of some kind disclosing your information. However, because a “sale” has a specific
definition under the law, it does not include all situations in which payment
of some kind is received for the disclosure.
For example, a disclosure for which we charge a fee to cover the cost to
prepare and transmit the information does not qualify as a “sale” of your
Inmates. If you are an inmate of a correctional
institution or in the custody of law enforcement, we may release medical
information about you to the correctional institution or law enforcement
official who has custody of you, if the correctional institution or law
enforcement official represents to Gastonia Medical Specialty Clinic PA that such medical information is necessary: (1) to
provide you with health care; (2) to protect your health and safety or the
health and safety of others; (3) to protect the safety and security of officers,
employees, or others at the correctional institution or involved in
transporting you; (4) for law enforcement to maintain safety and good order at
the correctional institution; or (5) to obtain payment for services provided to
you. If you are in the custody of the
North Carolina Department of Corrections (“DOC”) and the DOC requests your
medical records, we are required to provide the DOC with access to your
YOUR RIGHTS REGARDING MEDICAL INFORMATION
You have the following rights regarding medical information we maintain
Right to Inspect and Copy. You have the
right to inspect and receive a copy of your medical record unless your attending
physician determines that information in that record, if disclosed to you,
would be harmful to your mental or physical health. If we deny your request to inspect and
receive a copy of your medical information on this basis, you may request that
the denial be reviewed. Another licensed
health care professional chosen by Gastonia Medical Specialty Clinic PA will
review your request and the denial. The
person conducting the review will not be the person who denied your
request. We will do what this reviewer
have all or any portion of your medical information in an electronic format, you may request an electronic copy of those records
or request that we send an electronic copy to any person or entity you
designate in writing.
Your medical information is
contained in records that are the property of Gastonia Medical Specialty Clinic PA. To inspect or receive a copy of medical information
that may be used to make decisions about you, you must submit your request in
writing to Gastonia
Medical Specialty Clinic PA’s Privacy
Officer. 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, and we may collect the fee before
providing the copy to you. If you agree,
we may provide you with a summary of the information instead of providing you
with access to it, or with an explanation of the information instead of a
copy. Before providing you with such a
summary or explanation, we first will obtain your agreement to pay and will
collect the fees, if any, for preparing the summary or explanation.
Right to Amend. If you feel that medical
information we have about you in your record 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 Gastonia
Medical Specialty Clinic PA.
request an amendment, make your request in writing to Gastonia Medical Specialty
Clinic PA’s Privacy Officer. In addition, you must provide a reason that
supports your request.
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
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 Gastonia Medical Specialty Clinic PA;
Is not part of
the information that you would be permitted to inspect and copy; or
determined to be accurate and complete.
If we deny your request for an
amendment, you may submit a written statement of disagreement and ask that it
be included in your medical record.
Right to an Accounting of Disclosures. You have the
right to request a list of certain disclosures we have made of medical information
about you during the past six years.
request this list or accounting of disclosures, submit your request in writing
Medical Specialty Clinic PA’s Privacy
Officer and state whether you want the list on paper or electronically. Your request must state a time period that
may not be longer than six years. The
first list you request within a 12-month period will be free. For additional lists, we may charge you for
the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw or modify your
request at that time before any costs are incurred. We may collect the fee before providing the
list to you.
Right to Request Restrictions. Except where
we are required to disclose the information by law, you have the right to
request a restriction or limitation on the medical information we use or
disclose about you. For example, you
could revoke any and all authorizations you previously gave us relating to
disclosure of your medical information.
are not required to agree to your request, with the exception of restrictions on disclosures to your health
plan, as described below. If we do agree, we will comply with your
request unless the information is needed to provide you with emergency
request restrictions, make your request in writing to Gastonia Medical Specialty
Clinic PA’s 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.
may request that we not disclose your medical information to your health
insurance plan for some or all of the services you receive during a visit to
Medical Specialty Clinic PA location. If
you pay the charges for those services you do not want disclosed in
full at the time of such service, we are required to agree to your
request. “In full” means the amount we
charge for the service, not your copay, coinsurance, or deductible
responsibility when your insurer pays for your care. Please note that once information about a
service has been submitted to your health plan, we cannot agree to your
request. If you think you may wish to
restrict the disclosure of your medical information for a certain service,
please let us know as early in your visit as possible.
Ø Right to
Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact
you at work or by mail, or at another mailing address other than your home
address. We will accommodate all
reasonable requests. We will not ask you
the reason for your request. To request
confidential communications, make your request in writing to the Privacy
Officer and specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the
right to a paper copy of this notice or any revised 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.
obtain a paper copy of this notice, request a copy from Gastonia Medical Specialty
Clinic PA’s Privacy Officer in writing.
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 at Gastonia Medical Specialty
Clinic PA’s office. The notice will contain the effective date on
the first page, in the top right-hand corner.
If the notice changes, a copy will be available to you upon request.
INVESTIGATIONS OF BREACHES OF PRIVACY
will investigate any discovered unauthorized use or disclosure of your medical
information to determine if it constitutes a breach of the federal privacy or
security regulations addressing such information. If we determine that such a breach has
occurred, we will provide you with notice of the breach and advise you what we
intend to do to mitigate the damage (if any) caused by the breach, and about the
steps you should take to protect yourself from potential harm resulting from
If you believe your privacy rights have been violated,
you may file a complaint with Gastonia Medical Specialty Clinic PA
or with the Secretary of the United States Department of Health and Human
Services. To file a complaint with Gastonia Medical Specialty
Clinic PA, contact Gastonia Medical Specialty
Clinic PA’s Privacy Officer by mail at
1021 X-Ray Drive, Gastonia, NC 28054. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
uses and disclosures of medical information not covered by this notice may be
made only with your written authorization or as required by law. If you authorize us to use or disclose
medical information about you, you may revoke that authorization, in writing,
at any time. Your revocation will be
effective as of the end of the day on which you provide it in writing to Gastonia Medical Specialty
Clinic PA’s Privacy Officer. If you revoke your permission, we will no
longer use or disclose medical information about you for the purposes that you previously
had authorized in writing. You
understand that we are unable to take back any disclosures we have already made
with your permission, and that we are required to retain our records of the
care that we provided to you.