NOTICE OF PRIVACY PRACTICES

Effective Date: September 23, 2013

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.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that information about you and your health is personal. We are committed to protecting your health information. We will create a record of the care and services you receive at Carolina Center for Specialty Surgery, its subsidiaries and other entities. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will apply to all of the records of your care generated by CCSS. This notice will tell you about the ways we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

1. Make sure that health information that identifies you is kept private.
2. Give you this notice of our legal duties and privacy practices with respect to your health information.
3. Follow the terms of the notice that is currently in effect.
4. Provide notice to you in the event that we become aware of a breach of your unsecured health information.

WHO WILL FOLLOW THIS NOTICE?

This notice describes CCSS’s practices and that of:

1. Any health care professional authorized to enter information into your medical record, including doctors on the medical staff.
2. All departments and units of CCSS
3. All employees, staff, volunteers and other CCSS personnel.
4. In addition, these CCSS facilities may share health information with each other for treatment, payment or healthcare operations purposes as described in this notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION.

The following categories describe different ways that we may use and disclose health 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 at least one of the categories.

For Treatment.

We may use your health information to provide you with medical treatment or services. We may disclose your health information to doctors, nurses, technicians, medical students, or other CCSS personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different CCSS departments may also share your health information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We may also disclose your health information to people outside of CCSS to provide services that are a part of your medical care.

Treatment for Drug and Alcohol Use & Mental Health Issues.

If you receive treatment, including counseling or other medical treatment, for drug or alcohol use or mental health issues, we will not release any of this treatment information to anyone unless you authorize us to do so or a court of law gives us an order to do so.

HIV & AIDS Treatment.

If you are tested or receive treatment for HIV or AIDS, we will not release any information about your test results or treatment, except in the following circumstances:

1. You give us permission to release this information.
2. We are required or permitted by law to disclose this information.
3. A court order or subpoena requires us to release this information.

Unemancipated Minors – Treatment for Pregnancy; Drug & Alcohol Abuse; Venereal Disease; Emotional Disturbance.

If you are under the age of 16 and are not married and have not been emancipated by a court of law, we will not reveal any information about any treatment you receive for pregnancy, drug and/or alcohol abuse, venereal disease or emotional disturbances, except in the following circumstances:

1.  Your doctor determines that this information needs to be shared with your parents because there is a serious threat to your life or health.
2. If your parent or guardian contacts your doctor and specifically asks about your treatment for one of the 4 conditions listed above.

For Payment.

We may use and disclose your health information so that your treatment and services provided by CCSS may be billed and payment may be collected from you, an insurance company or a third party. For example, we may tell your insurance company about a treatment you are going to receive to obtain prior approval or to determine whether your insurance will cover the treatment. We may also need to give your insurance company information about a surgery you had at a CCSS facility so that your insurance company will pay us or reimburse you for the surgery.

For Health Care Operations.

We may use and disclose your health information for healthcare operations. This is necessary to run CCSS and give quality care to our patients. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many CCSS patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may disclose information to doctors, nurses, technicians, medical students, and other CCSS personnel for review and learning purposes.

Appointment Reminders.

We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at CCSS.

Treatment Alternatives.

We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services.

We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.

Business Associates.

There are some services provided in our organization through contacts with business associates. For example, we may use a copy service to make copies of your medical record. When we hire companies to perform these services, we may disclose your health information to these companies so that they can perform the job we’ve asked them to do and bill you or your insurance company for the services rendered. To protect your health information, however, we require the business associate through a written agreement to appropriately safeguard your health information and to be obligated to the same restrictions that you impose upon us with respect to the use and disclosure of your health information.

Individuals Involved in Your Care or Payment for Your Care.

We may release your health information to a family member, other relative, close personal friend, or any other person who is involved in your care or payment related to your care.

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. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific needs, so long as the medical information they review does not leave the clinic. In most circumstances we will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the clinic.

To Avert a Serious Threat to Health or Safety.

We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or reduce the threat.

SPECIAL SITUATIONS

Disaster Relief.

We may release your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Organ and Tissue Donation.

We may release health 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 transplantation.

Military and Veterans.

If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation.

We may release your health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks.

We may disclose your health information for public health activities. These activities generally include the following:

1. To prevent or control disease, injury or disability.
2. To report births and deaths.
3. To report child abuse or neglect.
4. To report reactions to medications or problems with products.
5. To notify people of recalls of products they may be using.
6. 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.
7. To notify the appropriate government authority if we believe an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities.

We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government 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 may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement.

We may release health information if asked to do so by a law enforcement official:

1. In response to a court order, subpoena, warrant, summons or similar process.
2. To identify or locate a suspect, fugitive, material witness, or missing person.
3. About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
4. About a death we believe may be the result of criminal conduct.
5. About criminal conduct at CCSS.
6. In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors.

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information to funeral directors as necessary for them to carry out their duties.

National Security and Intelligence Activities.

We may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may also disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates.

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) for the safety and security of the correctional institution.

Blood Testing.

While you are receiving care, a health care worker may accidentally be exposed to blood or other body fluids. If this occurs, your blood will be tested for the presence of certain diseases (for example, HIV, Hepatitis B and C). These tests are necessary to help protect the health care worker. The results of these tests will be a part of your medical record and will not be released except with your prior consent or as required or permitted by law.

OTHER USES OF HEALTH INFORMATION.

Other uses and disclosures of health information not covered by this notice or the laws that apply to us, including uses or disclosures for most marketing purposes and any sale of your health information, except for sales of your health information related to your treatment or as otherwise permitted by law, will be made only with your written authorization. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization.

You understand that we are unable to take back any disclosures we have already made with your permission. We are required to retain records of the care that we provided to you.

North Carolina Law.

In the event that North Carolina Law requires us to give more protection to your health information than stated in this notice or required by Federal Law, we will give that additional protection to your health information.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.

You have the following rights regarding the health information we maintain about you:

Right to Inspect and Copy.

You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include psychotherapy notes or psychiatric/substance abuse notes. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Medical Records Director of the appropriate CCSS treatment facility (location). You may request either an electronic or paper copy of your records. We may charge a fee for the actual costs of copying, mailing or other supplies associated with your request. We will respond to you within 30 days of receiving your written request. We may deny your request to inspect and/or obtain a copy of your health information in limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request an Amendment.

If you feel that health information we have about you 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 CCSS. To request an amendment, your request must be made in writing to the Chief Privacy Officer, 225 Baldwin Ave, Charlotte, North Carolina, 28204. In addition, you must provide a reason that supports your request. We will respond within 60 days of receiving your written request.

We 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 that:

1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
2. Is not part of the health information kept by or for CCSS.
3. Is not part of the information which you would be permitted to inspect and copy.
4. Is accurate and complete.

Right to Request an Accounting of Disclosures.

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made concerning your health information; but, does not include disclosures made for treatment, payment, or for healthcare operations, or for purposes or disclosures specifically authorized by you.

To request this list or accounting of disclosures, you must submit your request in writing to the Chief Privacy Officer, 225 Baldwin Ave, Charlotte, North Carolina 28204. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. 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 will respond within 60 days of receiving your request. The list will include the date of the disclosure, to whom health information was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. To request restrictions, you must make your request in writing. 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. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You may not limit uses and disclosures that we are legally required or allowed to make. However, we are required to agree to your request for a restriction of a disclosure of your health information to a health plan if the health information pertains solely to a health care item or service for which you, or someone on your behalf, has paid us in full.

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 at home.

To request confidential communications, you must make your request in writing to the Chief Privacy Officer, 225 Baldwin Ave, Charlotte, North Carolina, 28204. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must 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. You may obtain a copy of this notice at any time from our website, www.carolinaspecialtysurgery.com, or from the CCSS facility where you obtained treatment.

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 health information we already have about you as well as any information we receive in the future. The notice will contain the effective date on the first page. You can view the current notice at our website, www.carolinaspecialtysurgery.com. We will post a copy of the current Notice of Privacy Practices at each CCSS treatment facility.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with CCSS or with the Secretary of the Department of Health and Human Services.

If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact the Chief Privacy Officer at (704) 376-1605.

You will not be penalized for filing a complaint.