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.

Effective Date: January 2017

Purpose of Privacy Notice

The purpose of the “Notice of Privacy Practices” is to inform you about how your health information may be used within Springwell Network, Inc. as well as reasons why your health information may be sent to other entities.

This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights. The Notice also explains how to contact us should you have questions or comments about the policies and procedures Springwell Network uses to protect the privacy of your health information.

Springwell Network will ensure that internal mechanisms are in place to protect oral, written and electronic PHI across the organization. Electronic information shall also be protected by an automated system that allows limited access, as required by law. Springwell Network protects PHI whenever records are removed from any location, or when being transported from one location to another.

Our Responsibilities

We are required by law to protect the privacy of your protected health information (PHI), and to provide you with a Notice of our legal duties and privacy practices associated with your PHI. We are also required to follow the terms of this Notice. We will provide you a paper copy of this Notice prior to or when you become enrolled in Springwell Network’ system. We reserve the right to revise or change the terms of this Notice at any time and to make the new revisions effective for all health information we maintain. Whenever there are changes to this Notice we will inform you by:

• Posting the revised notice in our offices;
• Making copies of the revised Notice available upon request (either at our offices or through the Privacy Officer listed in this Notice); and
• Posting the revised Notice on our website – ______________________________

We are required by law to notify you of any breach of your unsecured PHI.

Uses and Disclosures of Health Information

There are certain times when we may use or disclose your PHI. When we disclosure your PHI, we will comply with any and all requirements surrounding the disclosures, including, but not limited to, those found in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended by the Health Information Technology for Economic and Clinical Health Act, (“HITECH”), 42 C.F.R. Part 2, and North Carolina General Statutes Chapter 122C.

When We Must Disclose Your PHI

We are required to disclose health information about you, under certain circumstances:

• To you, or your authorized representative, upon request
• To the Secretary of the Department of Health and Human Services, upon request, to determine if we are complying with the Privacy Rule

How We May Use and Disclose Your PHI

• For Treatment Purposes

We may use and disclose your PHI to coordinate, and/or manage your healthcare and related services. For example, we may use or disclose health information about you when you need a prescription filled, when we consult with another healthcare provider about your care, or to emergency treatment providers when you need emergency services. To the extent any of your PHI includes records covered under 42 C.F.R. Part 2, we will comply with the terms and conditions of those regulations regarding disclosure for treatment purposes.

• For Payment Purposes

We may use and disclose your PHI to pay providers for the healthcare services you receive, and determine if appropriate claims are paid. For instance, we may use or disclose health care information about you when auditing a provider’s claims, to determine if the claims submitted are backed by proper documentation. To the extent any of your PHI includes records covered under 42 C.F.R. Part 2, we will comply with the terms and conditions of those regulations regarding disclosure for payment purposes.

• To Perform Business Health Care Operations

We may use and disclose you PHI in performing our business activities called “health care operations.” These healthcare operations allow us to improve the quality of care we provide and reduce healthcare costs. For example, we may use or disclose your PHI for internal quality improvement activities. We may also use and disclose your PHI for the healthcare operations of our providers. For example, we may use or disclose health information about you for internal quality improvement activities of a provider that has treated you. To the extent any of your PHI includes records covered under 42 C.F.R. Part 2, we will comply with the terms and conditions of those regulations regarding use or disclosure for healthcare operations purposes.

Additional Use and Disclosure of Health Information without your Authorization

State and federal laws require or allow that we share your health information with others in specific situations without your consent. Prior to disclosing your health information, we will evaluate each request to ensure that only the minimum necessary information will be disclosed.

We may disclose health information about you for the following reasons. Before we make any disclosures for these reasons, we will ensure any required circumstances for disclosure are met:

• If the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law (for instance, as required under North Carolina General Statutes Chapter 122C);
• For public health activities, such as for the purpose of preventing or controlling disease;
• To report child abuse or neglect to a public health authority or other appropriate government authority authorized by law to receive such reports;
• For purpose of activities related to monitoring an FDA-regulated product, to a person subject to the jurisdiction of the FDA;
• For health oversight activities, including, but not limited to, civil, administrative, and criminal proceedings;
• In response to a court order or subpoena;
• For certain law enforcement purposes, such as for the purpose of identifying or locating a suspect or fugitive;
• To law enforcement, if you are believed to be the victim of a crime;
• To a coroner, for purposes of identifying a deceased person, determining cause of death, or other duties required by law, or to funeral directors so they may carry out their duties;
• For research purposes;
• To avert a serious threat to health or safety;
• To determine eligibility for or entitlement to benefits under laws administered by the Secretary of Veterans Affairs;
• For certain military, national security, and intelligence purposes;
• To a correctional institution or other law enforcement official having lawful custody of an inmate;
• To a relative, friend, or to any other person you identify, provided the information is directly relevant to that person’s involvement with your health care or payment for that care;
• To Springwell Network’ business associates to assist with administering your benefits;
• For worker’s compensation purposes; or
• For eligibility purposes

Certain Uses and Disclosures with Your Authorization

We will not use or disclose psychotherapy notes without your written authorization, except as allowed or required by law.

We will not market or sell your health information without your written authorization, except as allowed or required by law.

You may revoke a written authorization provided for any of the above purposes at any time; however, the revocation will not apply to any actions we have already taken in reliance on the authorization.

We will not use or disclose your PHI without your written authorization for any purpose not identified in this notice, except as allowed.

Your Rights

1. Your PHI will not be disclosed without your authorization, unless allowed or required by law.
2. You have the right to request, in writing, restrictions on certain uses and disclosures of your health information. We will make reasonable effort to accommodate your request; however, with limited exceptions, we are not required to agree to these restrictions.
3. If you sign a written authorization allowing us to use and disclose your PHI, you may revoke that authorization at any time. The revocation will be effective as of the date of your revocation and will not apply to any actions we have already taken in reliance on the authorization.
4. You have the right to request, in writing, to review and receive copies of your PHI. There may be a charge for making copies of your requested health information. There are circumstances where we may be unable to grant your request to review records.
5. You have the right to request, in writing, to amend existing information that is part of your protected health information. There are certain situations where we will be unable to grant your request to amend your protected health information.
6. You have the right to request, in writing, a list of certain disclosures we have made regarding your health information. This does not include disclosures we have made for treatment, payment, or healthcare operations purposes, and certain other purposes. Your first request will be provided to you free of charge. However, if you request a list of disclosures more than once in a 12 month period, you may be charged a reasonable fee. We will inform you of the cost incurred and you may choose to withdraw or modify your request at that time, before any costs are incurred. There are certain exceptions that apply.
7. You have a right to request, in writing, confidential communications or to be contacted at a different address or phone number, or by any other appropriate manner, about your health information.
8. Our Notice of Privacy Practices is posted electronically on our website at _________________. You have the right to receive a hard copy of our Notice of Privacy Practices. You may request a copy by calling 1-336-661-7788.

How To File a Complaint About Our Privacy Practices

If you believe your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures; or if you have questions and would like additional information, you may write or call our Privacy Officer at:

Privacy Officer
3820 North Patterson Avenue

Winston-Salem, NC 27105

Phone 336-661-7788

You may also file a written complaint, by mail or fax, to the Secretary of the United States Department of Health and Human Services at:

Office for Civil Rights
U.S. Department of Health and Human Services – 404-562-7886
61 Forsyth Street, SW – Suite 3B70 – 404-331-2867 (TDD)
Atlanta, GA. 30323 – 404-562-7881 (FAX)

If you file a complaint with our Privacy Officer or the Secretary, we will not take any action against you or change our management of your care in any way.

Downloadable Spanish Privacy Policy