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 UNDERSTANDING YOUR HEALTH RECORD/INFORMATION:

Each time you visit Cleveland Ambulatory Services for an interview or procedure, a record of your visit is created. This record contains your name, address, date of birth, social security number and other personal identifiable information. Your record will also contain the procedure that you are having done as well as a history and physical, possibly lab results and other diagnostic procedure results. This record serves as a basis for planning your care and treatment and serves as a means of communication among the many health care professionals who cotnribute to your care. Understanding what is in your record and how your personal health information is used helps you ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others.
Copy enclosed

YOUR HEALTH INFORMATION RIGHTS:

Unless otherwise required by law your health record is the physical property of Cleveland Ambulatory Services, the information belongs to you. You have the right to request a restirction on certain uses and disclosures of your information. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect, and obtain a copy of your heatlh record, obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.

OUR RESPONSIBILITIES:

Cleveland Ambulatory Services is required to maintain the privacy of your health information. In addition, provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should the information in this notice change, you would receive a copy with the changes upon admission. The notice will contain the effective date at the end of the notice. A copy of the current Notice of Privacy Practices is posted in both waiting rooms at CAS. We will not use or disclose your health information without your authorization, except as discribed in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:

If you have questions and would like additional information, you may contact Shayne Turner, Privacy Officer, at 704-482-1331. If you believe your privacy rights have been violated, you can file a complaint with Shayne Turner @ the above number, with the Secretary of Health and Human Services @ 202-690-7000 or the Office of Civil Rights @ 866-OCR-PRIV (866-627-7748). There will be no retaliation for filing a complaint.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATIONS

     We will use your health information for treatment. For example; Information obtained by healthcare practitioners will be recorded in your record and used to determine the course of treatment that should work best for you. By way of example, your physician will document in your record their expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations (example varies by practitioner type). We will also provide your physician or a subsequent healthcasre provider with copies of various reprots that should assist him or her in treating you once you're discharged from this facility. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
     We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or memebers of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

     Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for an interview or scheduled procedure at CAS or to follow up with you by phone after your procedure.
     Business Associates: There may be some services provided in our organization through contracts with business associates. Examples include physician services in radiology, certain laboratory tests, and a dictation service we use when your physician dictates your health record. When these services are contracted, we may disclose some or all of your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
     Directory: We may include certain limited information about you in the CAS facility directory while you are a patient at the facility. This information may include your name, location in the facility, your general condition (e.g., good, fair, serious, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy affiliated with your faith, such as a priest or rabbi, even if they don't ask for you by name.
     Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
     Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other responsible person health information relevant to that person's involvement in your care or payment related to your care.
     Research: We may disclose health information to researchers when an institutional review board that has reviewed the research proposal, and established protocols to ensure the privacy of your health information has approved their research.
     Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
     Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
     Marketing: We may contact you to provide appointment reminders.
     Food and Drug Administration(FDA): As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
     Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other siimilar programs established by law.
     Public health: As required by law, we may disclose your health information to public heatlh or legal authorities charged with preventing or controlling disease, injury, or disability.
     Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution of agents thereof health information necessary for your health and the health and safety of other individuals.
     Law enforcement: We may disclose health information for law enforcement puproses as required by law or in repsonse to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public heatlh authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentiolly endangering one or more patients, workers or the public.
     Blood Testing: While you are receiving care, a health care worker may accidentally be exposed to blood or other body fluids. If this occurs, your blood will be tested for the presence of certain diseases (for example, HIV, Hepatitis B and C). These tests are necessary to help protect the health care worker. The results of these tests will be a part of your medical record and will not be released except with your prior consent or as required or permitted by law.
     Notice of Privacy Practices availability: This notice will be prominently posted in the office where registration occurs. Patients will be provided a hard copy.
     Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or at home. To request confidential communications, you must make your request in writing to the Privacy Officer, 1100 North Lafayette St., Shelby, N.C. 28150. We will not ask you the reason for your request. We will accomodate all reasonable requests. Your request must specify how or where you wish to be contacted.

     EFFECTIVE DATE: April 14, 2003