HIPAA Privacy Notice

SALEEBY AND WESSELS PROCTOLOGY
NOTICE OF PRIVACY PRACTICES
EFFECTIVE APRIL 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. WE ARE REQUIRED BY LAW TO GIVE YOU THIS NOTICE.

Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. Understanding what is in your medical record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED:

For Treatment. We may use and disclose protected health information about you to provide you with medical treatment or services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you. For example, we may disclose information to people outside of our office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.

For Payment. We may use and disclose protected health information to obtain reimbursement for the health care provided to you. We may also use this information to obtain prior authorization for proposed treatment or to determine whether your plan will cover the treatment. We will also share this information with our billing service as needed to facilitate their efforts towards reimbursement from you or your insurance company.

For Healthcare Operations. We may use and disclose protected health information to support functions of our practice related to treatment and payment such as case management and quality assurance. In addition, we may use your health information to evaluate staff performance, to help us decide what additional services we offer, and other management and administrative activities.

Appointment Reminders. We may contact you to remind you that you have an appointment or need a referral for an appointment. Treatment Issues. We may call you with test results, to tell you about treatment options or alternatives, or to respond to your phone call and answer questions about your treatment.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits, services or medical education classes that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your protected health information to your family or friends or any other individual identified by you when they are involved in your care or the payment for your care. We will only disclose the protected health information directly relevant to their involvement in your care.

Emergencies. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably possible after the delivery of your treatment.

Communication Barriers. We may use or disclose your protected health information if we have attempted to obtain consent from you but are unable to do so due to substantial communication barriers and we determine that your consent to receive treatment is clearly inferred from the circumstances.

Required by Law. We may use or disclose protected health information about you when required by federal, state or local law. The disclosure will be limited to the relevant requirements of the law.

Public Health Risks. We may use or disclose your protected health information for public health reasons in order to prevent or control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Communicable Diseases. We may disclose your protected health information, if required by law, to a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading the disease or condition.

Health Oversight Activities. We may disclose protected health information to federal or state agencies that oversee our activities.

Legal Proceedings. We may disclose protected health information in response to a court or administrative order or in response to a subpoena, discovery request or other lawful process.

Law Enforcement. We may release protected health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process subject to all applicable legal requirements.

Workers Compensation. We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

Military Activity and National Security. If you are or were a member of the armed forces or part of the National Security and Intelligence communities we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Coroners, Medical Examiners and Funeral Directors. We may disclose personal health information to a coroner or medical examiner if necessary to identify a deceased person or determine the cause of death. Protected health information may also be used and disclosed for cadaver organ, eye or tissue donation purposes.

Research. We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals your identity.

Business Associates. There may be some services provided in our organization through contracts with Business Associated. Examples include our billing services, transcription services, and answering services, etc. When these services are contracted, we may disclose some of your protected health information to our Business Associate so that they can perform their job. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.

Inmates. We may use or disclose your protected health information if your are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use or disclose protected health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

YOUR HEALTH INFORMATION RIGHTS:

You have the right to inspect and obtain a copy of your protected health information. This means you may inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply. This request must be made in writing to our Practice Administrator.

You have the right to request a restriction of your protected health information. This means you may ask us to restrict or limit disclosure of any part of your protected health information. 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 payment for your care. You must state the specific restriction requested and to whom you want the restriction to apply. However, this request is subject to our approval. If the physician believes it is in your best interest to permit use and disclosure of your information, it will not be restricted. If the physician does agree to the requested restriction, we may not use or disclose your protected health information unless it is needed to provide emergency treatment. You may request a restriction by speaking to your treating physician and/or the Practice Administrator.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. You must make this request in writing to our Practice Administrator and your request must specify how or where you wish to be contacted. We will not ask you the reason for your request.

You have the right to request a correction to your protected health information. This means you may request an amendment of your medical record if you believe the health information we have about you is incorrect or incomplete. You must make this request in writing. Forms are available for this purpose and can be obtained from the Practice Administrator. We may deny your request for an amendment if we feel it is inaccurate, or if the amendment you are requesting is part of the record that was not created by us. If we deny your request for amendment, you have the right to have your request and our denial added to your medical record.

You have the right to receive an accounting of disclosures of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operation, or for disclosures that occurred prior to April 14, 2003. You must make this request in writing to the Administrator and this request must include a time frame, which may not be longer than 6 years or may not include dates prior to April 14, 2003.

You have the right to obtain a paper copy of this notice from us. This may be obtained by contacting the Administrator or the office manager at your physician’s clinical office location.

You have the right to register a complaint if you feel your privacy rights have been violated. If you believe your privacy rights have been violated, you may file a complaint with our office by contacting the Administrator by phone (919) 787-2542 or by mail (Saleeby Proctology, 3814 Browning Place, Suite 100, Raleigh, NC 27609). You may also file a complaint with the Secretary of the Department of Health & Human Services. You will not be penalized for filing a complaint.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described above. You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on the use or disclosure indicated on the authorization.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and 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 summary of the current notice in the office with its effective date at the top. You are entitled to a copy of the notice currently in effect. This notice will be posted on our website at www.saleebyproctology.com