Hipaa Notice Of Privacy Practices Form - North Carolina (Page 2 of 2) in pdf

of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section

164.500.

Other Permitted and Required Uses and Disclosures Will be Made Only With Your Consent, Authorization or Opportunity

to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s

practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not

inspect or copy the following records; psychotherapy notes; information compiled on reasonable anticipation of, or use in, a

civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits

access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or

disclose any part of your protected health information for the purpose of treatment, payment or healthcare operations. 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 of for notification purposes as described in this Notice of Privacy Practices. Your request must state the

specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to

permit use and disclosure of your protected health information, your protected health information will not be restricted. You

then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communication from us by alternative means or at an alternative

location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept

this notice alternatively i.e. electronically.

You have the right to have your physician amend your protected health information. If we deny your request for

amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and

will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health

information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to

object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Service if you believe your privacy rights have been violated

by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against

you for filing a complaint.

This notice is effective in its entirety as of April 14, 2003.

CONTACT INFORMATION

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy

practices with respect to protected health information. If you have any objections to this form, please ask to speak with our

HIPAA Compliance Officer in person or by phone at our Main Phone Number (910)893-5402.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name __________________________ Signature _______________________ Date: __________________________

First Choice Community Health Centers, Inc.

Corporate Compliance Program

Hipaa Notice Of Privacy Practices Form - North Carolina Page 2