When complete, please fax to (919) 363-7697 along with patient’s demographics and insurance.
**PLEASE ATTACH A PHOTOCOPY OF
PATIENT FACE SHEET ***
SENIOR HEALTH AND EDUCATION PARTNERS, PLLC
NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
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
During the course of providing services and care to you, SHAE Partners gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is charac-terized as your “protected health information.” This Notice of Privacy Practices describes how SHAE Partners maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.
B. SHAE Partners’S RESPONSIBILITIES
SHAE Partners is required by federal and state law to maintain the privacy of your pro-tected health information. SHAE Partners is also required by law to provide you with this Notice of Privacy Practices that describes SHAE Partners’s legal duties and privacy practices with respect to your protected health information. SHAE Partners will abide by the terms of this Notice of Privacy Practices. SHAE Partners reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions ef-fective for all protected health information that it maintains, including protected health information already in its possession. If SHAE Partners changes its Notice of Privacy Practices, it will personally deliver or mail a revised notice to you at your current address.
C. USE AND DISCLOSURE WITH YOUR AUTHORIZATION
SHAE Partners will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly per-mitted or required by law without your authorization. SHAE Partners has prepared an authorization form for you to use that authorizes SHAE Partners to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. SHAE Partners then will not use or disclose your protected health information, except where it has al-ready relied on your authorization.
D. HOW SHAE Partners MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION
1. Permissive Disclosures
SHAE Partners may, in its discretion, use or disclose your protected health with-out your written authorization in the following circumstances:
a. Your Care and Treatment
SHAE Partners may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For exam-ple, SHAE Partners may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. SHAE Partners may also disclose your pro-tected health information to individuals who will be involved in your care if you leave the SHAE Partners.
b. Billing and Payment
i. Medicare, Medicaid and Other Public or Private Health Insurers – SHAE Partners may use or disclose your protected health infor-mation to public or private health insurers (including medical in-surance carriers, HMOs, Medicare, and Medicaid) in order to bill and receive payment for your treatment and services that you re-ceive at the facility. The information on or accompanying a bill may include information that identifies you, as well as your diag-nosis, procedures, and supplies used. SHAE Partners will electron-ically transmit required health information according to Federal and State requirements.
ii.Health Care Providers – SHAE Partners may also disclose your pro-tected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed.
c. Health Care Operations
SHAE Partners may use your protected health information for health care operations at SHAE Partners. These uses and disclosures are necessary to manage the facility and to monitor our quality of services and care. For example, we may use your protected health information to review our ser-vices and to evaluate the performance of our staff in caring for you.
d. Licensing and Accreditation
SHAE Partners may disclose your protected health information to any government or private agency, such as to the North Carolina Department of Health Services and the North Carolina Department of Social Services, responsible for licensing or accrediting SHAE Partners so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licen-sure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.
e. SHAE Partners’s Special Directory
SHAE Partners maintains a Special Directory of patients to allow staff to provide certain basic information to members of the clergy who serve SHAE Partners or to other persons who ask for patients by name. Unless you notify SHAE Partners that you object, it will include certain limited information about you, such as your name, your location in SHAE Part-ners, your general condition, and your religious affiliation in its Special Directory.
f. Individuals Involved in Your Care or Payment for Your Care
Unless you specifically object, SHAE Partners may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person’s involvement with your care or directly relevant to payment relat-ed to your care. SHAE Partners may also disclose your protected health information to these same individuals to assist in notifying them of your location, general condition, or death.
g. Disaster Relief
SHAE Partners may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.
h. Business Associates
SHAE Partners may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, quality assur-ance, legal, or accounting services. SHAE Partners may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on the SHAE Partners’s be-half. SHAE Partners will have a contract with its business associates that obligate the business associates to maintain the confidentiality of your pro-tected health information.
i. Hospital Peer Review
SHAE Partners may disclose your protected health information to hospital medical staffs to aid in the credentialing of applicants and in the peer re-view of members.
j. Organ Procurement
SHAE Partners may disclose your protected health information following your death to an organ procurement agency or tissue bank in order to aid in using your organs or tissues in transplantation.
k. Appointment Reminders
SHAE Partners may use or disclose your protected health information to remind you about appointments.
l. Treatment Alternatives or Health-Related Benefits and Services
SHAE Partners may use or disclose your protected health information to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.
m. Members of Workforce
It is SHAE Partners’s policy to allow members of its workforce to share patients’ protected health information with one another to the extent necessary to permit them to perform their legitimate functions on SHAE Partners’s behalf. At the same time, SHAE Partners will work with and train its workforce members to ensure that there are no unnecessary or extraneous communications that will violate the rights of its patients to have the confidentiality of their protected health information maintained.
SHAE Partners may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.
o. Workers’ Compensation
SHAE Partners may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.
SHAE Partners will disclose protected health information to outside persons or entities without your written authorization as required by law in the following cir-cumstances:
a. Court Order; Order of Administrative Tribunal
SHAE Partners will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency.
SHAE Partners will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.
c. Law Enforcement Agencies
SHAE Partners will disclose protected health information to law enforce-ment agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons.
SHAE Partners will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to noti-fy next of kin; or to investigate deaths that may involve public health con-cerns, suspicious circumstances, elder abuse, or organ or tissue donation.
e. Elder Abuse Reporting
SHAE Partners will disclose protected health information about a patient who is suspected to be the victim of elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain cir-cumstances, SHAE Partners may disclose further protected health infor-mation about the patient to aid the investigating agency in performing its duties. SHAE Partners will promptly inform the patient about any disclo-sure unless SHAE Partners believes that informing the patient would place the patient in danger of serious harm, or would be informing the patients personal representative, whom the Provider believes to be responsible for the abuse, and believes that informing such person would not be in the pa-tient’s best interest.
f. National Security and Intelligence Activities, Protected Services for the Patient and Others
SHAE Partners will disclose protected health information about a patient to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the Patient of the United States, certain other persons or foreign heads of states, or to conduct cer-tain special investigations.
g. Other Disclosures Required by Law
SHAE Partners will disclose protected health information about a patient when otherwise required by law.
E.YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION
You have the following rights with respect to your protected health information. To ex-ercise these rights, contact SHAE Partners at the following address: SHAE Partners, 5306 NC Hwy 55, Suite 105, Durham, NC 27713 Attention: Privacy Official.
a. Right to Request Access
You have the right to inspect and copy your protected health information main-tained by SHAE Partners. In certain limited circumstances, SHAE Partners may deny your request as permitted by law. However, you may be given an opportuni-ty to have such denial reviewed by an independent licensed health care profes-sional.
b. Right to Request Amendment
You have the right to request an amendment to your protected health information maintained by SHAE Partners. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an oppor-tunity to submit a written statement disagreeing with the denial.
c. Right to Request Restriction
You have the right to request restrictions on the use and disclosure of your pro-tected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. SHAE Partners is not required to grant your re-quest, but if it does, it will comply with your request, except in an emergency sit-uation or until the restriction is terminated by you or SHAE Partners.
d. Right to Request Confidential Communications
You have the right to request that SHAE Partners communicate protected health information to the recipient by alternative means or at alternative locations.
e. Right to an Accounting
You have the right to receive an accounting of disclosures of your protected health information created and maintained by SHAE Partners over the six years prior to the date of your request or for a lesser period. SHAE Partners is not re-quired to provide an accounting of the following disclosures:
•To carry out treatment, payment, and health care operations;
•To respond to your requests for access to protected health information;
•To include your information in the SHAE Partners’s Special Directory;
•To aid in the identification or care of a patient; or
•To any recipient prior to April 14, 2003 or for protected health information cre-ated more than six years before the date of your request for an accounting.
f. Right to Receive a Copy of the Notice of Privacy Practices
You have the right to request and receive a copy of SHAE Partners’s Notice of Privacy Practices for Protected Health Information in written or electronic form.
If you believe that your privacy rights have been violated, you may file a complaint with SHAE Partners at the following address: 5306 NC Hwy 55, Suite 105, Durham, NC 27713. Attention: Administrator.
SHAE Partners will not retaliate against you if you file a complaint.
The effective date of this Notice of Privacy Practices is October 15, 2014
Each client has the right to treatment, including access to medical care and habilitation, regard-less of age or degree of disability. G.S. 122C-51. Each client has the right to an individualized treatment plan. Each client has the right to be free from unnecessary or excessive medication. Medication shall not be used for punishment, discipline, or staff convenience. SHAE Partners Physicians, Physician Assistants, and Nurse Practitioners will prescribe medications in accordance with accepted medical standards and will document such prescriptions and such medications in the client's record. Unless treatment is under court order, each client or legally responsible person, or health care agent named pursuant to a valid health care power of attorney, has the right to consent to or refuse treatment offered by SHAE Partners. Consent may be withdrawn at any time by the person who gave consent. If treatment is refused, the clinician should determine whether treatment in some other modality is possible. If all appropriate treatment modalities are refused, the client may be discharged from services unless treatment is court-ordered.
SHAE Partners employees do not inflict or recommend corporal punishment of any client. SHAE Partners employees do not order or use physical restraints, seclusion, or isolation. Each client shall be free from unwarranted invasion of privacy. Generally, SHAE Partners staff does not conduct searches of the client or his/her living area or seizures of property, but SHAE Partners may recommend such searches to be conducted in accordance with facility policies.
SHAE Partners will provide each client/legally responsible person seen under a Mental Health Contract with a written summary of client rights. Clients shall be informed of their rights to contacts Disability Rights North Carolina (DRNC), the statewide agency designated under State law to protect and advocate for the rights of persons with disabilities. Explanation shall be in a manner consistent with the client's or legally responsible person's level of comprehen-sion.
A grievance is defined by Senior Health and Educations Partners, PLLC (SHAE) as:
Client complaint or expression of dissatisfaction regarding service delivery, or any
expression of dissatisfaction by the service provider.
a. Client or service provider expresses dissatisfaction verbally or in writing.
b. SHAE staff member will attempt to resolve situation with the client or service
c. If this is not possible, then the SHAE staff who receives complaint shall
notify Terrence Laster, Quality Assurance Coordinator, who will document the complaint in the
Grievance Log. The Grievance Log shall include the following information:
Client ID# (not name)
Nature of complaint
Identification of those involved
Date complaint received and by whom
Summary of follow-up activities
Date grievance referred to QA Committee, if necessary
Date of resolution
d. The Quality Assurance Coordinator will be responsible for collecting relevant
information about the grievance, for taking action to resolve the grievance and for
documenting all progress.
e. The Quality Assurance Coordinator will attempt to resolve the complaint between the
parties involved. If no satisfaction results, and disenrollment or termination of a contract
might be appropriate, the Quality Assurance coordinator will present the situation to the
Quality Assurance Committee for a decision.
f. Thirty days after expressing grievance, clients or service providers will receive in writing
all grievance facts and decisions.
If this procedure is not clear, or you have any questions, please call Agency Director
at (919) 457-1517