Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 

HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. The HIPAA Privacy Rule created national standards to protect individuals’ medical records and other personal health information. These privacy rights protect your health information. These rights are important for you to know. You can exercise these rights, ask questions about them, and file a complaint if you think your rights are being denied or if your health information isn't being protected.

NOTICE OF PRIVACY PRACTICES of

FirstHealth of the Carolinas Inc.

FirstHealth Moore Regional Hospital

FirstHealth Montgomery Memorial Hospital

FirstHealth Moore Regional Hospital-Richmond

FirstHealth Moore Regional Hospital-Hoke 

Foundation of FirstHealth Inc.

and other health care providers, physicians and allied health providers credentialed by FirstHealth of the Carolinas while performing their duties within our health system.

 The terms of this notice apply to the organizations and groups of individuals listed above who provide services within our clinically integrated health care setting. Only records that relate to services or care at facilities that are part of the FirstHealth of the Carolinas health system are covered under this notice.

This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information.

FirstHealth has a legal duty to protect health information about you.

If you have any questions or concerns, please ask the registration staff for assistance.

Summary of FirstHealth’s Notice of Privacy Practices
FirstHealth has a legal duty to protect health information about you.

FirstHealth may use and disclose Protected Health Information (PHI) about you:

• To provide your health care treatment
• To obtain payment for services
• For health care operations (business operations related to your treatment)

FirstHealth may use and disclose your PHI in other circumstances without your authorization. (Some examples are federal law, state law, abuse/neglect cases, for tissue/organ donation.)

• FirstHealth may contact you to provide appointment reminders.
• FirstHealth may contact you with information about treatment, services, products or health care providers.
• FirstHealth may also contact you for fundraising activities.

You have rights about your PHI. You can:

• Request limits on uses and release of your PHI
• Request different ways to contact you
• See and receive copies of your PHI upon your request
• Request changes to your PHI
• Request a list of disclosures FirstHealth has made
• Request a copy of this notice

You can object to certain uses and disclosures. You can file a complaint about our privacy practices.

FirstHealth May Use and Disclose Your PHI
Without Your Authorization in the Following Circumstances:

1. FirstHealth may use and disclose your PHI to provide health care treatment to you.
   FirstHealth may use and disclose your PHI to provide, coordinate, or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and the coordination and management of your health care with others. For example, we may use and disclose your PHI when you need a prescription, lab work, an X-ray, or other health care services. In addition, we may use and disclose your PHI when referring you to another health care provider.

EXAMPLE 1: A doctor treating you for a broken leg may need to know if you have diabetes, because diabetes can slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Departments of the hospital may also need to share your PHI in order to coordinate different services you may need, such as prescriptions, lab work and X-rays. We may also disclose PHI about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as home health providers or others who may provide services that are part of your care.

EXAMPLE 2: Your doctor may share medical information about you with another health care provider. For example, if you are referred to another doctor, that doctor will need to know if you are allergic to any medications. Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.

NOTE: Entities and individuals who provide care as part of our clinically integrated health care system may share PHI with each other as necessary to carry out treatment, payment and health care operations.

1. FirstHealth may use and disclose PHI about you to obtain payment for services.
   Generally, FirstHealth may use and give your medical information to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, we may share information about these services with your insurance company/companies health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. FirstHealth may also share portions of your medical information with the following:
2. FirstHealth may use and disclose your PHI for health care operations.
   FirstHealth may use and disclose PHI in performing business activities, which we call “health care operations.” These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. Examples of the way we may use or disclose PHI about you for “health care operations” include the following:
3. FirstHealth may use and disclose your PHI under other circumstances without your authorization.
   FirstHealth may use and/or disclose your PHI for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:
4. You can object to certain uses and disclosures.
   Unless you object, FirstHealth may use or disclose your PHI in the following circumstances:
5. FirstHealth may contact you to provide appointment reminders.
   FirstHealth may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
6. FirstHealth may contact you with information about treatment, services, products or health care providers.
   FirstHealth may use and/or disclose PHI to manage or coordinate your health care. This may include telling you about treatments, services, products and/or other health care providers. We may also use and/or disclose PHI to give you gifts of a small value. 
   For example: If you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
7. FirstHealth may contact you for fundraising activities.
   FirstHealth may use and/or disclose your PHI, including disclosure to a foundation that may contact you to raise money for the hospital and its operations. We would release only contact information and the dates you received treatment or services at the hospital. If you do not want to be contacted in this way, you must notify our Privacy Office in writing.
8. North Carolina (N.C.) Law.
   There are circumstances where N.C. law requires more protection of your health information than stated in this notice or required by federal law. In these situations, we will provide the additional protections that are required. For example, we comply with additional confidentiality protections relating to communicable diseases such as HIV and AIDS. We also comply with state law confidentiality protections specific to treatment for mental health and substance abuse. Excluding exceptions permitted by law, such as disclosures to other facilities or professionals when necessary to coordinate your care or treatment or to a health care provider in an emergency, state law generally requires that we obtain your written authorization before we disclose treatment information related to mental health, developmental disabilities or substance abuse services.

• Billing departments or business offices
• Collection departments or agencies
• Insurance companies, health plans and their agents that provide your insurance coverage or payment for your health care
• Hospital departments that review the care you received to see if it and the costs associated with it were appropriate for your illness or injury
• Consumer reporting agencies (e.g., credit bureaus)
  For example: Let’s say you have a broken leg. FirstHealth may need to give your health plan(s) information about your condition, supplies used (such as plaster for your cast or crutches) and services you received (such as X-rays or surgery). The information is given to our billing department and your health plan so FirstHealth can be paid or you can be reimbursed. We may also send the same information to our hospital department, which reviews our care of your illness or injury.

• Reviewing and improving the quality, efficiency and cost of care that FirstHealth provides to you and our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided to others.
• Improving health care and lowering costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of people. FirstHealth may use PHI to identify groups of people with similar health problems to give them information, for instance, about treatment alternatives, classes or new procedures.
• Reviewing and evaluating the skills, qualifications and performance of health care providers taking care of you.
• Providing training programs for students, trainees, health care providers or non-health-care professionals (for example, billing clerks or assistants, etc.) to help them practice or improve their skills.
• Cooperating with outside organizations that assess the quality of the care FirstHealth and others provide. These organizations might include government agencies or accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations.
• Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty. For example, FirstHealth may use or disclose PHI so that one of our nurses can become certified as having expertise in a specific field of nursing, such as pediatric nursing.
• Assisting various people who review our activities. For example, PHI may be seen by doctors reviewing the services provided to you and by accountants, lawyers and others who assist us in complying with applicable laws.
• Planning for our organization’s future operations and fundraising for the benefit of our organization.
• Conducting business management and general administrative activities related to our organization and the services it provides, including providing information.
• Resolving grievances within our organization.
• Reviewing activities and using or disclosing PHI in the event FirstHealth sells our business, property or gives control of business or property to someone else.
• Complying with this Notice and with applicable laws.

• When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
• When the use and/or disclosure is necessary for public health activities. For example, FirstHealth may disclose your PHI if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
• When the disclosure is related to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for health oversight activities. For example, FirstHealth may disclose your PHI to a state or federal health oversight agency that is authorized by law to oversee our operations.
• When the disclosure is for judicial and administrative proceedings. For example, FirstHealth may disclose your PHI in response to an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes. For example, FirstHealth may disclose your PHI in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
• When the use and/or disclosure relates to decedents. For example, FirstHealth may disclose your PHI to a coroner or medical examiner for the purposes of identifying you should you die.
• When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
• When the use and/or disclosure relates to medical research. Under certain circumstances, FirstHealth may disclose your PHI for medical research.
• When the use and/or disclosure is to avert a serious threat to health or safety. For example, FirstHealth may disclose your PHI to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
• When the use and/or disclosure relates to specialized government functions. For example, FirstHealth may disclose your PHI 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.
• When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, FirstHealth may disclose your PHI to a correctional institution having lawful custody of you.

• FirstHealth may share your name, your room number and your condition (for example, good, fair, serious or critical) in our hospital directory with members of the clergy (or their designees) and with people who ask for you by name. We also may share your religious affiliation with clergy. If you object to such disclosures, you can opt out of the hospital directory at admitting or by contacting the Patient Privacy Officer.
• FirstHealth may share with a family member, relative, friend or other person identified by you PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death.
• FirstHealth may share your PHI with a public or private agency (for example, American Red Cross) for disaster relief purposes. Even if you object, FirstHealth may still share your PHI, if necessary, for the emergency circumstances.
  If you would like to object to our use or disclosure of your PHI in the above circumstances, please contact the Privacy Office.

State law also permits a hospice, home health, and ambulatory surgery or outpatient cardiac rehabilitation patient to object in writing to having state licensing inspectors review their health information during a licensure survey. We will comply with such written objections.

If you apply for and receive substance abuse services from us, federal law generally requires that we obtain your written consent before we may disclose information that would identify you as a substance abuser or a patient for substance abuse services. There are exceptions to this general requirement. For example, we may disclose information to our workforce as needed to coordinate your care, to agencies or individuals who help us carry out our responsibilities in serving you, and to health care providers in an emergency.

** Any Other Use or Disclosure of Your PHI Requires Your Written Authorization **

Under any circumstances other than those listed above, FirstHealth will ask for your written authorization before we use or disclose your PHI. If you sign a written authorization allowing us to disclose your PHI in a specific situation, you can later cancel your authorization in writing. If you cancel your authorization in writing, we will not disclose your PHI after we receive your cancellation, except for disclosures that were being processed before we received your cancellation.

You Have Several Rights Regarding Your PHI.

You have the right to request that FirstHealth restrict the use and disclosure of your PHI. We are not required to agree to your requested restrictions. However, even if we agree to your request, your restrictions may not be followed in certain situations. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection 4 of the previous section of this Notice. You may request a restriction by contacting the FirstHealth of the Carolinas Privacy Office in writing.

You have the right to request how and where FirstHealth contacts you about PHI. Your request must be in writing to the FirstHealth Privacy Office. For example, you can request that FirstHealth contact you at your work address or phone number or by e-mail. We must accommodate reasonable requests, but may condition that accommodation on your providing us with information regarding how payment (if any) will be handled and your specification of an alternative address or other method of contact. You may request alternative methods of communication by contacting the FirstHealth of the Carolinas Privacy Office in writing.

You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. Your request must be in writing. We may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of your PHI, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial. You may request to see and receive a copy of PHI about you by contacting the FirstHealth of the Carolinas Privacy Office in writing.

You have the right to request that FirstHealth makes amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) in those circumstances described in the previous underlined section. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received your PHI and who need the amendment. You may request an amendment of your PHI by contacting the FirstHealth of the Carolinas Privacy Office in writing.

If you ask our Privacy Office in writing, you have the right to receive a written list of our disclosures of your PHI. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003.) We are not required to include disclosures:

• For your treatment
• For billing and collection of payment for your treatment
• For our health care operations
• Requested by you that you authorized or that are made to individuals involved in your care
• Allowed by law when the use and/or disclosure relate to certain specialized government functions or relate to correctional institutions and in other law enforcement custodial situations, and
• As part of a limited set of information that does not contain certain information that would identify you

The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by contacting the FirstHealth of the Carolinas Privacy Office in writing.

You have the right to a copy of this Notice. You have the right to request a paper copy of this Notice at any time by contacting the FirstHealth of the Carolinas Privacy Office in writing. FirstHealth will make a good faith effort to provide a copy of this Notice no later than the date you first receive service from us (except in an emergency treatment situation and then FirstHealth will provide the Notice to you as soon as possible.)

You May File A Complaint About Our Privacy Practices.
If you think your privacy rights have been violated by us, or if you have a complaint about our privacy practices, you can contact the person listed below:
FirstHealth of the Carolinas
Attn: Privacy Office
P.O. Box 3000
Pinehurst, NC 28374
Toll-free (866) 898-8891

If you file a complaint, FirstHealth will not take any action against you or change our treatment of you in any way. You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.