The Children’s Clinic
NOTICE OF PRIVACY PRACTICES
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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS
IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and
state law to maintain the privacy of your medical information. We are also required to give you this notice
about our privacy practices, our legal duties, and your rights concerning your
medical information. We must follow the
privacy practices that are described in this notice while it is in effect. This notice takes effect
We reserve the right to change our privacy
practices and the terms of this notice at any time, provided such changes are
permitted by applicable law. We reserve
the right to make the changes in our privacy practices and the new terms of our
notice effective for all medical information that we maintain, including
medical information we created or received before we made the changes. Before we make a significant change in our
privacy practices, we will change this notice and make the new notice available
upon request.
You may request a copy of our notice at any
time. For more information about our
privacy practices, or for additional copies of this notice, please contact us
using the information listed at the end of this notice.
Uses and Disclosures of
Medical Information
We use and disclose medical information
about you for treatment, payment, and health care operations. For example:
Treatment:
We may use your medical information to treat you or disclose your
medical information to a physician or other health care provider providing
treatment to you.
Payment:
We may use and disclose your medical information to obtain payment for
services we provide to you.
Health Care Operations: We may use and disclose your medical information
in connection with our health care operations.
Health care operations include quality assessment and improvement
activities, reviewing the competence or qualifications of health care
professionals, evaluating practitioner and provider performance, conducting
training programs, accreditation, certification,
licensing or credentialing activities.
To You and on Your
Authorization: You may give us written
authorization to use your medical information or to disclose it to anyone for
any purpose. If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or
disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your medical information for any reason except those
described in this notice.
To Your Family and Friends: We must disclose your medical information to
you, as described in the Individual Rights section of this notice. We may disclose your medical information to a
family member, friend or other person to the extent necessary to help with your
health care or with payment for your health care, but only if you agree that we
may do so.
Appointment Reminders: We may use your medical information to
contact you to provide appointment reminders.
Persons Involved In Care: We may use or disclose medical information to
notify, or assist in the notification of (including identifying or locating) a
family member, your personal representative or another person responsible for
your care, of your location, your general condition, or death. If you are present, then prior to use or
disclosure of your medical information, we will provide you with an opportunity
to object to
such uses or disclosures. In the event
of your incapacity or emergency circumstances, we will disclose protected
health information based on a determination using our professional judgment
disclosing only protected health information that is directly relevant to the
person’s involvement in your health care.
We will also use our professional judgment and our experience with
common practice to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of medical information.
Disaster Relief: We may use or disclose your medical
information to a public or private entity authorized by law or by its charter
to assist in disaster relief efforts.
Marketing Health Related Services. We may use your medical information to
contact you with information about health-related benefits and services or
about treatment alternatives that may be of interest to you. We may disclose your medical information to a
business associate to assist us in these activities.
Fundraising: We may use your medical
information to contact you for fundraising purposes. We will limit our use and disclosure to your
demographic information and the dates of your health care. We may disclose this information to a
business associate or foundation to assist us in fundraising activities. We will provide you with any fundraising
materials and a description of how you may opt out of receiving future
fundraising communications.
Research:
We may use or disclose your medical information for research purposes in
limited circumstances.
Death; Organ Donation: We may disclose the medical information of a
deceased person to a coroner, medical examiner, funeral director, or organ
procurement organization for certain purposes.
Required by Law: We may use or disclose your medical
information when we are required to do so by law. For example, we must disclose your medical
information to the U.S. Department of Health and Human Services upon request for
purposes of determining whether we are in compliance with federal privacy
laws. We may disclose your medical
information when authorized by workers’ compensation or similar laws. We may disclose your medical information to a
government agency authorized to oversee the health care system or government
programs or its contractors, and to public health authorities for public health
purposes.
Law Enforcement: We may disclose your medical information in
response to a court or administrative order, subpoena, discovery request, or
other lawful process, under certain circumstances. Under limited circumstances, such as a court
order, warrant, or grand jury subpoena, we may disclose your medical
information to law enforcement officials.
We may disclose limited information to a law enforcement official
concerning the medical information of a suspect, fugitive, material witness,
crime victim or missing person. We may
disclose the medical information of an inmate or other person in lawful custody
to a law enforcement official or correctional institution under certain
circumstances.
Abuse or Neglect: We may disclose your
medical information to appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may
disclose your medical information to the extent necessary to avert a serious
threat to your health or safety or the health or safety of others. We may disclose medical information when
necessary to assist law enforcement officials to capture an individual who has
admitted to participation in a crime or has escaped from lawful custody.
National Security: We may disclose to military authorities the
medical information of Armed Forces personnel under certain circumstances. We may disclose to authorized
federal officials medical information required for lawful intelligence,
counterintelligence, and certain other national security activities.
Use and Disclosure of Certain Types of
Medical Information: For certain types
of medical information we may be required to protect your privacy in ways more
strict than we have discussed in this notice.
We must abide by the following rules for our use or disclosure of
certain types of your medical information:
HIV
Information. We may not disclose HIV information unless
required by law, pursuant to an authorization or the disclosure is to you or
your personal representative; to health care personnel providing care to you; pursuant to
appropriate subpoena or court order; to persons who may be at risk of infection
in accordance with state rules.
Information Released to
State Department of Health and Human Services.
You may object to our disclosure of your medical information from our ambulatory
surgery facility to the North Carolina Department of Health and Human Services
when the Department conducts inspections or other reviews.
Alcohol
and Drug Abuse Information. We may not disclose your medical information
that contains alcohol and drub abuse information except to you, your personal
representative or pursuant to an authorization or as may be allowed by law.
Individual Rights
Access:
You have the right to look at or get copies of your medical information,
with limited exceptions. You may request
that we provide copies in a format other than photocopies. We will use the format you request unless we
cannot practicably do so. You must make
a request in writing to obtain access to your medical information. You may obtain a form to request access by
using the contact information listed at the end of this notice. You may also request access by sending us a
letter to the address at the end of this notice. If you request copies, you will be charged
for the copies, staff time to locate and copy your medical information, and
postage to mail the copies to you. If
you request an alternative format, we will charge a cost-based fee for
providing your medical information in that format. If you prefer, we will prepare a summary or
an explanation of your medical information for a fee. Contact us using the information listed at
the end of this notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of
instances in which we or our business associates disclosed your medical
information for purposes, other than treatment, payment, health care operations
or pursuant to an authorization and certain other activities, since
Restriction:
You have the right to request that we place additional restrictions on
our use or disclosure of your medical information. We are not required to agree to these
additional restrictions, but if we do, we will abide by our agreement (except
in an emergency). Any agreement we may
make to a request for additional restrictions must be in writing signed by a
person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is
so memorialized in writing.
Confidential Communication: You have the right to request that we
communicate with you about your medical information by alternative means or to
alternative locations. You must make your request in writing, and you must
state that the information could endanger you if it is not communicated by the
alternative means or to the alternative location you want. We must accommodate your request if it is
reasonable, specifies the alternative means or location, and provides
satisfactory explanation how payments will be handled under the alternative
means or location you request.
Amendment. You have the right to request that we amend
your medical information. Your request
must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create
the information you want amended and the originator remains available or for
certain other reasons. If we deny your
request, we will provide you a written explanation. You may respond with a statement of
disagreement to be appended to the information you wanted amended. If we accept your request to amend the
information, we will make reasonable efforts to inform others, including people
you name, of the amendment and to include the changes in any future disclosures
of that information.
Electronic Notice: If you receive this notice on our web site or
by electronic mail (e-mail), you are entitled to receive this notice in written
form. Please contact us using the
information listed at the end of this notice to obtain this notice in written
form.
Questions and Complaints
If you want more information about our
privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you are concerned that we may have
violated your privacy rights, or you disagree with a decision we made about
access to your medical information or in response to a request you made to
amend or restrict the use or disclosure of your medical information or to have
us communicate with you by alternative means or at alternative locations, you
may complain to us using the contact information listed at the end of this
notice. You also may submit a written
complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file
your complaint with the U.S. Department of Health and Human Services upon
request.
We support your right to the privacy of
your medical information. We will not
retaliate in any way if you choose to file a complaint with us or with the U.S.
Department of Health and Human Services.
Contact Office: WHA
Privacy Officer
Telephone: (910)
796-7701 Fax: (910) 341-3449
E-mail: privacy@wilmingtonhealth.com
Address: