HIPAA: NOTICE OF PRIVACY PRACTICE
Effective Date: 4/14/2003
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Louise Raleigh, Director, The University of North Carolina at Greensboro Speech and Hearing Center (336)334-3784.
WHO WILL FOLLOW THIS NOTICE
This notice describes the practices of The University of North Carolina Greensboro (UNCG) Speech and Hearing Center and the Department of Communication Sciences and Disorders in its main clinic on-campus and at its off-campus service delivery sites and that of:
- Any speech-language pathologist or audiologist authorized to enter information in your client folder.
- All sections and units of the Center.
- All students, both graduate and undergraduate, majoring in Communication Sciences and Disorders at The University of North Carolina at Greensboro.
- Any observers with prior approval of the Director of the Speech and Hearing Center based on free and informed consent of client.
- All employees, staff, and other clinic personnel at The University of North Carolina at Greensboro Speech and Hearing Center.
WHAT TERMS MEAN
- Protected Health Information or PHI: PHI refers to identifiable health information about you that is maintained or transmitted by the Center either electronically or otherwise. Examples of PHI are names, addresses, phone numbers, and social security numbers.
- “Use” versus “disclosure”: Use of PHI refers to use of your health information internal to the Center while disclosure of PHI refers to the disclosure of your health information outside of or external to the Center.
- “Minimum necessary”: In every instance we will disclose only the minimum amount of your health information necessary to accomplish the purpose of any request.
OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION
We understand that Protected Health Information (PHI) about you and your communication difference or disorder is personal. We are committed to protecting PHI about you. We create a record of the care and services you receive at The University of North Carolina Greensboro Speech and Hearing Center. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated and held by the Center.
This notice will tell you about the ways in which we may use and disclose PHI about you. We also describe your rights and certain obligations we have regarding the use and disclosure of PHI.
We are required by law to:
- make sure that PHI that identifies you is kept private;
- give you this notice of our legal duties and privacy practices with respect to PHI about you; and
follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU WITHOUT YOUR AUTHORIZATION
We will disclose only information or reports that we have created in the Center. These reports may include information from other sources. The following categories describe different ways that we use and disclose PHI. 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 one of these categories.
- For treatment. We may use PHI about you to provide you with treatment or services. We may disclose PHI about you to speech-language pathologists, audiologists, graduate and undergraduate students, and other clinic personnel who are involved in your care. For example, a speech-language pathologist treating you for a language problem may need to know if you have a hearing loss because a hearing loss may affect language development. In addition, the speech-language pathologist may need to communicate with a graduate student who will assist in your treatment. We also may disclose information about you to people outside the clinic who may be involved in your care, such as family members and others.
- For payment. We may use and disclose PHI about you so that treatment and services you receive at the Center may be billed and payment may be collected from you, an insurance company, or other third party. For example, we may need to disclose information about the hearing test you receive at the Center so your health plan will pay us. We also may tell your health plan about a treatment you are going to receive to determine whether your plan will cover the treatment.
- For health care operations. We may use and disclose PHI about you for Center operations. These uses and disclosures are necessary to run the Center and make sure that all of our clients receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We also may combine PHI about many clients to decide what additional Center services should be offered, what services are not needed, and whether new treatments are effective. We may disclose information to the professionals, staff, and students for review and learning purposes. We may combine the information with information from other clinical programs to compare how we are doing and to see where we can make improvements in the care and services we offer. We will remove information that identifies you from this set of PHI so others may use it to study health care and health care delivery without learning who the specific clients are.
- Appointment reminders. We may use and disclose PHI to contact you as a reminder that you have an appointment at the Center. For example, a graduate student may phone you the day before your appointment as a reminder. A message may be left on your answering machine or sent by e-mail or FAX.
- Treatment alternatives. We may use and disclose PHI 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 or disclose PHI to tell you about health related benefits or services that may be of interest to you.
- Observation of services. The Center is an educational facility for graduate and undergraduate students majoring in Communication Sciences and Disorders. With your consent we will allow students to observe services. In addition, personnel from other agencies involved with your care may be allowed to observe services. Even though your permission is not required by regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we will ask for your signed consent to be observed.
- Disclosures for instructional purposes. During the course of evaluation and treatment, video and audio recordings may be used, from time to time, by students and faculty in the Department of Communication Sciences and Disorders for instructional purposes. Instructional uses may occur in regularly scheduled classes in Communication Sciences and Disorders, special professional seminars, and continuing education programs. In addition, we may disclose certain information in classes taught at the university and in other professional presentations. Unless we have your consent to use PHI, we will remove information that identifies you so students and professionals may use it to study health care and health care delivery without learning who specific clients are. Even though not required by HIPAA, we will ask for your consent for these disclosures.
- Research. Under certain circumstances, we may use and disclose PHI about you for research purposes provided the HIPAA 1996 regulations are met as approved by UNCG’s Institutional Review Board.
- As required by law. We will disclose PHI about you when required to do so by federal, state, or local law.
- To avert serious threat to health or safety. We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety, and to the safety of the public or another person.
- Workers’ compensation. We may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness.
- Public health risks. We will disclose PHI about you for public health activities. These activities generally have the following purposes:
- To prevent or control disease, injury or disability
- To report child abuse or neglect
- To report problems with products
- To notify people of recalls of products they may be using
- To notify the appropriate government authority if we believe a client has been the victim of domestic violence. We will only make this disclosure if you agree or when we are required or authorized by law to do so.
- To notify the appropriate government authority if we believe a client has been the victim of abuse or neglect.
- Health oversight activities. We may disclose PHI to an 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 programs, and compliance with civil rights laws.
- Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Collection agency. In the event that your account is long past due and that you have failed to return a letter of notification to the Center, your account with PHI may be assigned to a Credit Bureau Collection Center for enforcement of collection. Only the minimum information necessary will be provided.
- Law enforcement. We may release PHI if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons, or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About criminal conduct at the clinic.
- National security and intelligence activities. We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you 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; or 3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
You have the following rights regarding PHI we maintain about you.
- Right to inspect and copy. You have the right to inspect and request a copy of PHI that may be used to make decisions about your care. To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Center office. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
- We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to Protected Health Information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Center 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. If you disagree with our denial, you have a right to appeal. Your appeal would be reviewed by a third party.
- Right to amend. If you think that Protected Health Information we have about you is incorrect or incomplete, you may ask us to amend the information and to notify others who may have received the incorrect PHI. You have the right to request an amendment for as long as the information is kept by or for the Center.
- To request an amendment, your request must be made in writing and submitted to the Center Director. In addition, you must provide a reason that supports your request.
- We may deny your request for an amendment if it is not in writing and does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not a part of the information kept by or for the Center;
- Is not a part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
- Right to an accounting of disclosures. You have a right to request a list of certain disclosures made of your PHI. The list will not include disclosures made for the purposes of treatment, payment, healthcare operations, national security, law enforcement/corrections, and certain oversight activities. To request this list or accounting of disclosures, you must submit your request in writing to the Center Director. Your request must state a time period, which may not be longer than seven years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request in a 12-month period will be free. For additional lists, we may charge you for the cost 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.
- Right to request restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or health care operations; however, you cannot request a restriction that will inhibit our ability to conduct treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure you had.
We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If we deny your request, we will inform you in writing.
- To request restrictions, you must make your request in writing to the Center Director. 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.
- Right to request confidential communications. You have the right to request that we communicate with you about personal health matters in a certain way or at a certain location. For example, you can request that we contact you at work or by mail.
To request confidential communications, you must make your request in writing to the Center Director. 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 a right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
You may obtain a copy of this Notice at our website:
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. If we change the Notice, we will apply it to the PHI we already have about you as well as any information we may create or receive in the future. We will post a copy of the current Notice in the Center and on our web site. The Notice will contain on the first page the effective date. In addition, the revised Notice will be available at the client registration window in the Center.
If you believe your privacy rights have been violated, you may file a complaint with the Center or with the Secretary of the Department of Health and Human Services. To file a complaint with the Center, contact Louise Raleigh, Center Director, (336)334-3784. All complaints must be submitted in writing.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose PHI about you, you may revoke this permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose PHI about you 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, and that we are required to retain our records of the care we provide to you.