WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS

Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

Health Care Operations. Our practice may use and disclose your PHI to operate our business, including some services provided to us through contracts with business associates. When these services are contracted for, we may disclose PHI about you so they can perform the job we have asked them to do and bill you or your third party payer for services rendered. In order to protect your PHI, we require the business associate to appropriately safeguard the information. 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.

Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.

Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

Notification. Unless you object, we may use or disclose PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and your general condition.

Disclosures Required By Law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

Public Health Risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths


• Reporting child abuse or neglect


• Preventing or controlling disease, injury or disability


• Notifying a person regarding potential exposure to a communicable disease


• Notifying a person regarding a potential risk for spreading or contracting a disease or condition


• Reporting reactions to drugs or problems with products or devices


• Notifying individuals if a product or device they may be using has been recalled


• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information


• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health Oversight Activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary action; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by an other party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our office
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

Serious Threats to Health or Safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar programs.

If you receive services in North Carolina, some North Carolina State laws provide you more protection than HIPAA, and where applicable, we will follow the requirements of those State laws. The following North Carolina laws may apply to you:

• Under North Carolina law, minors, with or without the consent of a parent or guardian, have the ability to consent to services for the prevention, diagnosis and treatment of certain illnesses including: venereal disease and other diseases that must be reported to the State; pregnancy; abuse of controlled substances or alcohol; and emotional disturbance. Abortion services, however, still require the consent of the parent, guardian or grandparent with whom the minor has been living for at least six (6) months unless a court has determined that the minor should be treated as an adult. Minors may petition a court to waive this requirement for parental consent.
  
  
• If you request treatment and rehabilitation for drug dependence, your request will be treated as confidential. We will not disclose your name to any police officer or other law-enforcement officer unless you consent to your sharing of it. Even if we refer you to another person for treatment and rehabilitation, we will continue to keep our name confidential.
  

• If you suffer from a communicable disease (for example, tuberculosis, syphilis, or HIV/AIDS), information about your disease will be treated as confidential. Other than circumstances described to you in other sections of this notice, we will not release any information about your disease except as required to protect public health, prevent the spread of a disease, or at the request of the State or Local Health Director.

Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Please complete our PHI Designation Form to specify your preferred method of contact. This form can be updated at the time of an office visit or simply mailed to us at your convenience. Boylan Medical Associates will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing by completing the PHI Designation Form. Your request must describe in a clear and concise fashion:

Inspection and Copies. Although your health record is the physical property of our practice, the information belongs to you. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Dr. Mary J. Forbes, Boylan Medical Associates HIPAA Compliance Officer; 3900 Browning Place; Suite 101; Raleigh, NC 27609 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of personnel time, copying, and mailing associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Dr. Mary J. Forbes, Boylan Medical Associates HIPAA Compliance Officer; 3900 Browning Place, Suite 101; Raleigh, NC 27609. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless you prove the creator of the information is not available to amend the record.

Accounting of Disclosures. You have a right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for some purposes, not including treatment, payment, or health care operations. The accounting also will exclude certain other disclosures, such as disclosures made directly to you, incidental disclosures, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting , you must submit a request in writing to Dr. Mary J. Forbes, Boylan Medical Associates HIPAA Compliance Officer; 3900 Browning Place, Suite 101; Raleigh, NC 27609. Your request must specify the time period, but may not be longer than six (6) years from the date of disclosure and may not include dates before April 14,2003. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing any additional accounting. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time.

Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact any Boylan Medical Associates employee.

Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice by contacting Dr. Mary J. Forbes, Boylan Medical Associates HIPAA Compliance Officer; 3900 Browning Place, Suite 101; Raleigh, NC 27609. 919-781-9650. You will not be penalized for filing a complaint. You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact information can be found at the website for the Office of Civil Rights at www.hhs.gov/ocr.

Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact