HIPAA NOTICE OF PRIVACY PRACTICES
As required by the Privacy Regulations Promulgated Pursuant to the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI)
to carry out treatment, payment or health care operations (TPO) 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.
Uses and Disclosures of Protected Health Information: Your protected health information may be used and
disclosed by our organization, our office staff and others outside of our office that are involved in your care and
treatment for the purpose of providing health care services to you, to pay your health care bills, to support the
operation of the organization, and any other use required by law.
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 a
third party. For example, we would disclose your protected health information, as necessary, to a home health
agency that provides care to 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
Payment: Your protected health information will be used, as needed, to obtain payment for your health care
services. For example, obtaining approval for equipment or supplies coverage may require that your relevant
protected health information be disclosed to the health plan to obtain approval for coverage.
Healthcare Operations: We may use or disclose, as‐needed, your protected health information in order to support
the business activities of our organization. These activities include, but are not limited to, quality assessment
activities, employee review activities, accreditation activities, and conducting or arranging for other business
activities. For example, we may disclose your protected health information to accrediting agencies as part of an
accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your
protected health information, as necessary, to contact you to check the status of your equipment.
We may use or disclose your protected health information in the following situations without your
authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health
Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement,
Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and
Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the
Department of Health and Human Services to investigate or determine our compliance with the requirements of
Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or
Opportunity to Object, unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or this
organization has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights: Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may
not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation
of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is
subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not
to use or disclose any part of your protected health information for the purposes of treatment, payment or
healthcare 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.
Our organization is not required to agree to a restriction that you may request. If our organization believes it is in
your best interest to permit use and disclosure of your protected health information, your protected health
information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an
alternative location. 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 alternatively, e.g., electronically.
You may have the right to have our organization amend your protected health information. 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.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have
the right to object or withdraw as provided in this notice.
Complaints: 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 contact of your
complaint. We will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and
privacy practices with respect to protected health information, if you have any questions concerning or objections
to this form, please ask to speak with our President in person or by phone at 252‐744‐2426.
Associated companies with whom we may do business, such as an answering service or delivery service, are
given only enough information to provide the necessary service to you. No medical information is provided.
We welcome your comments: Please feel free to call us if you have any questions about how we protect your
privacy. Our goal is always to provide you with the highest quality services.