Joint Notice of Privacy Practices for Onslow County Hospital Authority
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: March 1, 2021
OUR DUTY TO PROTECT YOUR HEALTH INFORMATION
Onslow Memorial Hospital ("OMH") is committed to protecting your health information. We are required by law to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to abide by the terms of this Notice as currently in effect. Protected health information ("PHI") includes information that we collect about your past, present, or future health, health care we provide you, and payment for your care.
Changes to this Notice. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain. If we change this Notice, we will post a copy of the Notice at our facilities and on our website at www.onslow.org
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Federal law requires us to protect the privacy of your PHI. In addition, North Carolina law protects not only your rights of privacy, but also your relationship with your provider and, if applicable, your mental health provider. State law restricts the disclosure of your health information in many instances. However, we may disclose your health information under State and Federal law: for treatment, payment and health care operations; with your permission; pursuant to a court order; or as otherwise permitted or required by law.
North Carolina and federal law allow us to use and disclose your PHI without your written permission as follows:
- Treatment: We need to 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 coordinating and managing your health care with others. For example, we need to use and disclose your PHI, both inside and outside our system, when you need a prescription, lab work, an x-ray, or other health care services. This can be with different departments within the hospital sharing your health information to coordinate the provision of a service that you may need. In addition, we need to use and disclose your PHI when referring you to another health care provider.
- Payment: We may use and disclose your PHI to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, we may need to share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your health plan or policy and for approval of payment before we provide the services. We may also need to share medical information about you with the following:
- Collection departments or agencies, or attorneys assisting us with collections, including the State of North Carolina Office of the Attorney General.
- Insurance companies, health plans, and their agents.
- Consumer reporting agencies (e.g., credit bureaus).
- Others who are responsible for your bills, such as your spouse or a guarantor of your bills, as necessary for us to collect payment.
- Health care operations: OMH may use use and disclose your PHI to perform business activities, which we call "health care operations" that allow us to improve the quality of care we provide and reduce health care costs. We may need to disclose your PHI for the "health care operations" of other providers involved in your care to improve the quality, efficiency, and costs of their care or to evaluate and improve the performance of their providers. For example: members of the medical staff, the risk management team, or the quality improvement team, including Patient Safety Organizations, may use information in your health record to assess the care you receive and the outcomes of your treatment. We may also disclose information to doctors, nurses, technicians, medical students, and other OMH personnel for review and teaching purposes.
- Fundraising Activities: We may use and/or disclose certain PHI about you, including disclosure to one of our foundations and to contact you to raise money for our services and operations. You have the right to opt out of receiving these communications. If you do not want us to use your PHI to contact you for fundraising efforts, please notify the Privacy Officer by calling the number or write to the address listed on the last page of this Notice.
- Appointment Reminders: We may use and share health information to contact you by phone or mail as a reminder that you have an appointment for treatment or medical care.
- Treatment Alternatives and Health-Related Benefits and Services: We may use and share health information to tell you about or recommend possible treatment options, treatment alternatives, or health-related benefits or services that may be of interest to you.
We may use and disclose your PHI under other circumstances without your authorization or an opportunity to agree or object: We may use and/or disclose your PHI in a number of circumstances for which we need not seek your permission or give you an opportunity to agree or object, such as:
- When necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- To organizations that facilitate donation and transplantation of tissues and/or organs.
- To authorized officials when required by federal, state, or local law. For example: Reporting abuse or neglect of a child or disabled person or reporting certain types of wounds or injuries.
- In response to certain subpoenas, court orders, or administrative orders.
- As required by law, for public health activities. For example: preventing or controlling disease and reporting births and deaths.
- For authorized Worker's Compensation activities.
- To health oversight agencies. For example: agencies that enforce compliance with licensure or accreditation requirements.
- To law enforcement, such as in the event of certain crimes.
- To coroners, medical examiners, or funeral directors to carry out their duties.
- As required by military command authorities, if you are a member of the armed forces.
- To our business associates to carry out treatment, payment, or health care operations on our behalf. For example: we may disclose health information about you to a company who bills insurance companies for our services. However, to protect your health information, we require the business associate to appropriately safeguard your information by requiring that they enter into an appropriate agreement with OMH.
- For research or to collect information in databases to be used later for research. We may disclose your PHI, and surplus specimens, for research that is approved by an institutional review board that has determined that your written consent to the disclosure is not required. We may also review your PHI to determine if you are eligible to participate in a medical research study or to allow a researcher to contact you via phone, email, text message, or by mail to determine if you are interested in participating in a medical research study.
- To a correctional institution having lawful custody of you as necessary for your health and the safety of others.
- We can remove or aggregate identifiers so the information becomes anonymous and then use or share it without your written permission.
You can object to certain uses and disclosures: Unless you object, we may use or disclose your PHI in the following circumstances:
- Hospital or Facility Directories. We may share your location in the facility and your general condition (critical, serious, etc.) in our patient listing with people who ask for you by name. We also may share your religious affiliation with clergy.
- Individuals Involved in Your Care or Payment of Your Care. We may share your health information with a family member, personal representative, friend or other person you identify when information is directly related to their involvement in your care or payment for your care.
- Emergency Circumstances and Disaster Relief. We may share with a public or private agency (for example, American Red Cross) your PHI for disaster relief purposes. Even if you object, we may still share the PHI if necessary for the emergency circumstances. In an emergency, or if you are unable to make decisions for yourself, we will use our professional judgment to decide if it is in your best interest to share your PHI with a person involved in your care.
Some uses and disclosures of your PHI require your written permission: We will obtain your authorization in the event we may seek to:
- Use or disclose psychotherapy notes;
- Use or disclose your PHI for marketing purposes; or
- Sell any of your PHI.
We will also obtain your authorization for any other use and/or disclosure of your PHI not otherwise described in this Notice of Privacy Practices. If you authorize us to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the purpose(s) covered by your written authorization. However, we cannot take back any disclosures already made pursuant to a valid authorization. You may have additional rights under other laws: North Carolina laws may provide you with more protection for specific types of information than federal laws protecting the privacy of your PHI, and where applicable, we will follow the requirements of North Carolina law. North Carolina law generally requires that we obtain your written consent before we may disclose health information related to your mental health, developmental disabilities, or substance abuse services. There are some exceptions to this requirement. Certain alcohol, drug abuse and psychiatric treatment information may have special privacy protections: If you receive treatment in one of these programs or facilities, you will receive an additional notice related to the confidentiality of your health information. We will not disclose any health information identifying you as a patient of such a program or facility, or provide information relating to your treatment in such a program or facility, unless:
- You or your personal representative consents in writing.
- A court order requires disclosure.
- Medical personnel need information to treat you in a medical emergency.
- Qualified personnel use the information for research or operations activities.
- It is necessary to report a crime or a threat to commit a crime.
- It is necessary to report abuse or neglect as required by law.
Special provisions for minors under North Carolina Law: Under North Carolina law, minors, with or without the consent of a parent or guardian, have the right to consent to services for the prevention, diagnosis and treatment of certain illnesses including: venereal disease and other diseases that must be reported to the State of North Carolina; pregnancy; abuse of controlled substances or alcohol; and emotional disturbance. If you are under the age of 18, are not married and have not been legally emancipated or have joined the armed forces, you can consent to treatment for pregnancy, drug and/or alcohol abuse, venereal disease, or emotional disturbances without an adult’s consent. This information will remain confidential, unless your doctor determines your parents or guardian need to know this information because there is a serious threat to your life or health, or your parents or guardian have specifically asked about your treatment. Note that minors are still required to get parental or court consent for an abortion or court consent for sterilization. We may contact you by email, phone call, or text message: If you have provided us with an email address or a land line or mobile telephone number, we may use that information to contact you by email, phone call, or text message to coordinate your health care, make you aware of services that may benefit you or discuss your bill. Medical researchers affiliated with our partnership with UNCHCS may also use this information to offer you an opportunity to participate in an approved medical research study or communicate with you about a medical research study for which you are enrolled. Health Information Exchanges: Onslow Memorial Hospital may participate in one or more Health Information Exchanges (HIEs). An HIE is an electronic system that allows other health care providers treating you to access and share your medical information if they also participate in the HIE. OMH will share your PHI with the HIEs and may use the HIEs to access your PHI to assist in providing health care to you. OMH may also participate in North Carolina HealthConnex (the “Exchange”) through the North Carolina Information Exchange Authority. Entities that participate in the Exchange share your PHI with the Exchange and may use the Exchange to access your PHI to assist us in providing health care to you. If you do not want your PHI accessible to Exchange participants, you must opt out by submitting a form directly to the Exchange. The opt out form may be downloaded directly from the NC Health Information Authority Website (https://hiea.nc.gov/patients/your-choices). Information explaining the benefits of the exchange and instructions on how to opt out are available on the Exchange website as well. Even if you opt out of the Exchange, we may use your PHI available from the Exchange in order to provide emergency care to you or for public health or research purposes authorized by law. Your opt out will also not affect our obligation to disclose your PHI to the Exchange when you receive hospital services that are paid for by Medicaid or other NC State funded resources.
YOUR RIGHTS REGARDING YOUR PHI
You have the right to request restrictions on uses and disclosures of your PHI: You have the right to request that we restrict the use and disclosure of your PHI for treatment, payment, or health care operations; for us in a hospital or facility directory; or to family members and others involved in your care. But we are not required to agree to your requested restrictions in most circumstances. If we agree to your request, we will comply unless the information is needed to provide emergency treatment or is required to be disclosed by law or as otherwise described in this Notice. If you pay in full and in advance for certain items or services and request that we not disclose information about those items or services to your health plan, we will comply. All other requests for restrictions on the use or disclosure of your PHI must be made to us in writing. To request a restriction, you must submit your written request to the Onslow Memorial Privacy Officer. Please reference the contact information listed below. You have the right to request different ways to communicate with you: You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment will be handled and your specification of an alternative address or other method of contact. To request an alternative method of communication, you must submit your written request on the appropriate form to the Health Information Management Department. Forms are available on our website or by contacting the Health Information Management Department. You have the right to see and copy PHI about you: You have the right to request to see and receive a copy of your PHI contained in clinical, billing and other records used to make decisions about you that are part of our designated record set. You have the right to receive your copy of PHI in its original electronic version if possible or, if not possible, in another electronic format that is mutually agreeable to you and us. To view and/or copy your health information, you must submit your written request on the appropriate form to the OMH Health Information Management Department. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to see and obtain copies of your health information in certain very limited circumstances. You have the right to appeal the denial. You have the right to request amendment of certain of your PHI: If you think that your health and billing information is incorrect or incomplete, you may ask us to correct it. We may deny your request if:
- The information was not created by us.
- The information is not part of the records used to make decisions about your care.
- We believe the information is correct and complete.
- The request pertains to a part of the record that you do not have the right to review.
Your request must be in writing and must explain your reason(s) for the request. If we deny the request, 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 the PHI and who need the amendment. To request an amendment you must submit your written request on the appropriate form to the Health Information Management Department. Forms are available on our website or by contacting the Health Information Management Department. You have the right to a listing of certain disclosures of your PHI that we have made: You have the right to receive a written list of certain disclosures we have made of PHI about you. You may ask for disclosures made up to six (6) years before your request. We are required to provide a listing of all disclosures except the following:
- For your treatment.
- For billing and collection of payment for your treatment.
- For health care operations.
- Made to or requested by you, or that you authorized.
- Incidental to permitted uses and disclosures.
- Made to individuals involved in your care, for directory or notification purposes.
- Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations.
- As part of a limited set of information which does not contain certain information which 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, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information. If you request a list of disclosures more than once in a 12 month period, we can charge you a reasonable fee. To request a listing of disclosures, contact the Health Information Management Department to obtain a form to complete to make your request. You have the right to breach notification: You have the right to receive notice in the event of a breach of your unsecured PHI. 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 OMH Privacy Officer at (910) 577-2852. We will provide you with a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible). We will post a copy of the current Notice of Privacy Practices at each treatment facility and on our website: www.onslow.org.
CONTACTS FOR QUESTIONS AND COMPLAINTS
If you need more information about our privacy practices or have questions about this Notice, if you think we have violated your privacy rights, or if you want to complain to us about our privacy practices, you can contact the OMH Privacy Officer by phone, email, or US Mail using the contact information listed below: OMH Privacy Officer Onslow Memorial Hospital P.O. BOX 974Jacksonville, NC 28541-0974 Phone: (910) 577-2852Email: PrivacyOffice@Onslow.org If you file a complaint, we 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 Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/.