NOTICE OF PATIENT INFORMATION PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully.

BURKE PRIMARY CARE LEGAL DUTY

Burke Primary Care is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described below.

UNDERSTANDING HEALTH INFORMATION

Each time you visit our practice, a record of the visit is made. Typically this record contains your history, symptoms, examination and test results, diagnoses, treatment and a plan for your future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment
• means of communication among the health professionals who care for you or your child
• legal document describing the care you received
• means by which you are a third-party payer can verify that services billed were actually provided
• tool in educating health professionals
• source of data for medical research
• source of information for public health officials

Understanding what is in your record and how your health information is used helps you to ensure it is correct, better understand how your health information is shared with others and allows you to make informed decisions when authorizing disclosure to others. We will not use or disclose your health information without your authorization except as described in this notice.

HOW WE WILL USE OR DISCLOSE HEALTH INFORMATION

Treatment: We will use for health information for treatment. For example, we will record information we obtain during the visit in the medical record and share this information with other members of your healthcare team. We may provide a copy of your health information to other physicians that we refer you to assist them in treating you.

Payment: We will use your health information for payment. For example, a bill may be sent to your insurance company or third-party payer that includes information about the date you or your child was seen, the diagnosis and the services we provided.

Health Care Operations: We will use your health information for regular health operations. For example, we may use the information in the record to assess the care and treatments provided in our practice.

Business Associates: There are some services provided in our practice through contacts with business associates. Examples include our accountants, consultants and attorneys. When these services are provided, we may disclose health information to our business associates so they can perform the job we have asked them to do. To protect your information, we will require they appropriately protect this information.

Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative or close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment of services provided.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established methods to ensure the privacy of the information.

Funeral Directors: We may disclose health information to funeral directors and coroners to carry out the duties consistent with the law.

Organ Procurement Organizations: Consistent with the law, we may disclose health information to organ procurement organizations for their designated services.

Communication and Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.

Workers Compensation: We may disclose health information to the extent authorized by state law governing workers compensation health care services.

Public Health: As required by law, we may disclose health information to public health officials charged with preventing or controlling disease, injury or disability. For example, we are required to report certain communicable diseases we provide treatment for.

Correctional Institution: We may disclose to correctional institutions information regarding the care we have given when they are responsible for you.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Reports: We may disclose health information when directed by the appropriate federal oversight agency related to any complaints, surveys or requests.

YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of the practice, the information in the health record belongs to you.

You have the following rights:

• You may request that we not use or disclose information for a particular reason related to treatment, payment or health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form we will provide. Although we will consider your request, please be aware we are not obligated to accept or abide by it. We will review each request individually to determine if we can honor your request.
• If you would like to make a request to receive information from our office in another manner, you may request that we provide it by an alternative means. Such a request may be made in writing on a form we will provide. We will attempt to accommodate all reasonable requests.
• You may request to inspect and/or obtain copies of your or your child's health information. We may charge you a reasonable fee for copies. We will attempt to provide you with the information within thirty (30) days of your request.
• If you believe that any information in the record is incorrect or if you believe important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing on a form we will provide. You may request this form at the front desk.
• You may request a written accounting of all disclosures made of your protected health information. This request may be made for all information we have after April 14th, 2003. We will keep an accounting of these disclosures made OTHER THAN those disclosures for treatment, payment or health care operations as defined above for six years. We will respond to your request within thirty (30) days if possible. If you request an accounting more than once in a twelve-month period, you may be charged a reasonable fee.
• You have a right to obtain a paper copy of this notice.
• We must obtain a written authorization from you to disclose information for purposes other than treatment, payment or health care operations. You have the right to revoke this authorization, except to the extent we have already used or disclosed the information.

CONCERNS AND COMPLAINTS

If you are concerned that Burke Primary Care may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below.

You may also send a written complaint to the US Department of Health and Human Services.

For further information on Burke Primary Care's health information practices or if you have a complaint, please contact the privacy officer at Burke Primary Care.

Scott Gallagher
Privacy Officer
Burke Primary Care
103 Medical Heights Drive
Morganton, North Carolina 28655
Telephone: 828-437-4211
Fax: 828-437-5017

CHANGES TO THIS POLICY

Burke Primary Care may change or update this policy at any time. When changes are made, a new "Notice of Information Practices" will be posted in the waiting room and patient exam areas and will be provided at your next visit. You may also request an updated copy of our notice at any time.