WomanCare, P.A.
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.

WomanCare, P.A. is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Use and Disclosure of Protected Health Information Without Your Consent

1) Treatment

We may use and disclose your protected health information to provide, coordinate or manage your health care and related services.

Example: Your doctor may share medical information about you if you are referred to another doctor, or therapy provider. Information may be shared with a pharmacy when a prescription is called in for you.

2) Payment

We may use and disclose your protected health information to obtain payment for services.
Example: We will submit an itemized billing statement to your insurance carrier for payment to WomanCare for services rendered. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.

3) Health Care Operations

We may use and disclose your protected health information in performing health care operations.
Example: We may use and disclose your health information in reviewing and evaluating the skills, qualifications and performance of healthcare providers taking care of you.

Other circumstances in which we may use and disclose protected health information without your authorization or an opportunity to agree or object:
  • Workers’ Compensation
    We may use and disclose your protected health information as necessary to comply with State Workers’ Compensation Laws.

  • Emergencies
    We may use and disclose your protected health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

  • Public Health
    As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling communicable dis sease, injury or disability, reporting abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

  • Judicial and Administrative Proceedings
    We may disclose your protected health information in response to an order of a court, subpoena or administrative or judicial proceeding.

  • Law Enforcement
    We may disclose your protected health information to a law enforcement official for purposes of identifying or locating a suspect, fugitive, material witness or missing person, or to comply with laws that require the reporting of certain types of wounds or other physical injuries. We may also disclose information about you to a correctional institution having lawful custody of you.

  • Deceased Persons
    We may disclose your protected health information to coroners or medical examiners for the purpose of identifying you should you die.

  • Organ, Eye or Tissue Donation
    We may disclose your protected health information to organizations involved in procuring, banking, or transplanting organs and tissues.

  • Research
    Under certain circumstances we may disclose your protected health information to researchers conducting research that has been approved by an Institutional Review Board.

  • Public Safety
    It may be necessary to disclose your protected health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

  • Specialized Government Agencies
    We may disclose your protected health information about you if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President and medical suitability or determinations of the Department of State.

  • Marketing
    We may contact you for marketing purposes, as described below:
    Example: As a courtesy to our patients, it is our policy to call your home prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone.

  • Change of Ownership
    In the event that WomanCare is sold or merged with another organization, your protected health information/record will become the property of the new owner.
Your Rights Regarding Protected Health Information
  • You have the right to request restrictions on certain uses and disclosures of your protected health information. Please be advised, however, that WomanCare is not required to agree to the restriction that you requested.

  • You have the right to have your protected health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

  • You have the right to inspect and copy your protected health information.

  • You have a right to request that WomanCare amend your protected health information. Please be advised, however, that WomanCare is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

  • You have a right to receive an accounting of disclosures of your protected health information made by WomanCare, P.A.

You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

WomanCare reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, WomanCare is required by law to comply with this Notice.

If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: our Privacy Officer, by calling this office at (336) 765-5470. If the Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints
Complaints about your Privacy Rights, or how WomanCare has handled your protected health information should be directed to the Privacy Officer by calling this office at (336) 765-5470. If the Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within two (2) working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

This notice is effective as of April 14, 2003.
I have read the Privacy Notice and understand my rights contained in the notice.

By way of my signature, I provide WomanCare, P.A. with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

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Patient’s Name (print)


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Patient’s or Authorized Representative’s Signature Date

 

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Authorized Facility Signature Date