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.

If you have questions about this Notice, or would like to exercise your Privacy Rights, please contact the facility where you received treatment, or contact our Corporate Responsibility Office:

CaroMont Health Corporate Responsibility Office
2525 Court Drive Gastonia, NC 28054
1-877-785-0001 Corporate Responsibility Hotline
corporateresponsibility@caromonthealth.org

Our pledge regarding your medical information

CaroMont Health is committed to protecting your medical information. We strive to use only the minimum amount of your health information necessary for the purposes described in this Notice. We collect information from you and use it to provide you with quality care, and to comply with certain legal requirements. We are required by law to maintain the privacy of your health information, and to give you this Notice of our legal duties, our privacy practices, and your rights. We are required to follow the terms of our most current Notice. When we disclose information to other persons and companies to perform services for us, we will require them to protect your privacy. There are other laws we will follow that may provide additional protections, such as laws related to mental health, alcohol and other substance abuse, and communicable disease or other health conditions. This Notice covers the following sites and people: all health care professionals authorized to enter information into your chart, all volunteers authorized to help you while you are here, all our associates and on- site contractors, all departments and units within the hospital, all health care students, all health care delivery facilities and providers within the CaroMont Health system, and your personal doctor and others while they are providing care at this site. Your doctor may have different policies or notices about the health information that was created in his or her private office or clinic.

How we may use and disclose health information

Treatment

We may use and disclose your health information to provide treatment or services, to coordinate or manage your health care, or for medical consultations or referrals. We may use and disclose your health information among doctors, nurses, technicians, health care students and other personnel who are involved in taking care of you at our facilities or with such persons outside our facilities. We may use or share information about you to coordinate the different services you need, such as prescriptions, lab work and x-rays. We may disclose information about you to people outside our facility who may be involved in your care after you leave, such as family members, home health agencies, therapists, nursing homes, clergy, and others. We may give information to your health plan or another provider to arrange a referral or consultation.

Payment

We may use and disclose your health information so that we can receive payment for the treatment and services that were provided. We may share this information with your insurance company or a third party used to process billing information. If you pay for your health care entirely out-of-pocket, you may request that we not share your information with your insurance company. We may contact your insurance company to verify what benefits you are eligible for, to obtain prior authorization, and to tell them about your treatment to make sure that they will pay for your care. We may disclose information to third parties who may be responsible for payment, such as family members, or to bill you. We may disclose information to third parties that help us process payments, such as billing companies, claims processing companies, and collection companies.

Healthcare Operations

We may use and disclose your health information as necessary to operate our facility and make sure that all of our patients receive quality care. We may use health information to evaluate the quality of services that you received, or the performance of our staff in caring for you. We may use health information to improve our performance or to find better ways to provide care. We may use health information to grant medical staff privileges or to evaluate the competence of our health care professionals. We may use your health information to decide what additional services we should offer and whether new treatments are effective. We may disclose information to students and professionals for review and learning purposes. We may combine our health information with information from other health care facilities to compare how we are doing and see where we can make improvements. We may use health information for business planning, or disclose it to attorneys, accountants, consultants and others in order to make sure we are complying with the law. We may remove health information that identifies you so that others may use the de-identified information to study health care and health care delivery without learning who you are.

Health Information Exchanges

We may participate in health information exchanges to facilitate the secure exchange of your electronic health information between and among several health care providers or other health care entities for your treatment, payment, or other healthcare operations purposes. This means we may share information we obtain or create about you with outside entities (such as hospitals, doctors offices, pharmacies, or insurance companies) or we may receive information they create or obtain about you (such as medication history, medical history, or insurance information) so each of us can provide better treatment and coordination of your healthcare services. In addition, if you visit any CaroMont Health facility, your health information may be available to other clinicians and staff who may use it to care for you, to coordinate your health services or for other permitted purposes.

Appointment Reminders and Service Information

We may use or disclose your health information to contact you to provide appointment reminders, or to let you know about treatment alternatives or other health related services or benefits that may be of interest to you.

Individuals Involved In Your Care

We may give your health information to people involved in your care, such as family members or friends, unless you ask us not to. We may give your information to someone who helps pay for your care. We may share your information with other health care professionals, government representatives, or disaster-relief organizations, in emergency or disaster-relief situations so they can contact your family or friends or coordinate disaster-relief efforts.

Patient Directories

We may keep your name, location in the facility, and your general condition in a directory to give to anyone who asks for you by name. We may give this information and your religious affiliation to clergy, even if they do not know your name. You may ask us to keep your information out of the directory, but you should know that if you do, visitors and florists will not be able to find your room. Even if you ask us to keep your information out of the directory, we may share your information for disaster-relief efforts or in declared emergency situations.

Fundraising Activities

We depend extensively on private fundraising to support our health care missions. We may use your name and other limited information to contact you, including the dates of your care, but not your treatment information, so that we may provide you with an opportunity to make a donation to our fundraising programs. If we do contact you for fundraising purposes, you will be told how you may ask us not to contact you in the future.

Research

We may use or disclose your health information for research that has been approved by an official research review board, which has evaluated the research proposal and established standards to protect the privacy of your health information. We may use or disclose your health information to a researcher preparing to conduct a research project.

Organ and Tissue Donation

We may use or disclose your health information in connection with organ donations, eye or tissue transplants or organ donation banks, as necessary to facilitate these activities.

Public Health Activities

We may disclose your health information to public health or legal authorities whose official activities include preventing or controlling disease, injury, or disability. For example, we must report certain information about births, deaths, and various diseases to government agencies. We may disclose health information to coroners, medical examiners, and funeral directors as allowed by the law to carry out their duties. We may use or disclose heath information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using. We may use or disclose health information to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Serious Threat to Health and Safety

We may use or disclose your health information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. We will only disclose health information to someone reasonably able to help prevent or lessen the threat, such as law enforcement or government officials. Required by Law, Legal Proceedings, Health Oversight Activities, and Law

Enforcement

We will disclose your health information when we are required to do so by federal, state and other law. For example, we may be required to report victims of abuse, neglect or domestic violence, as well as patients with gunshot and other wounds. We will disclose your health information when ordered in a legal or administrative proceeding, such as a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to a law enforcement official to identify or locate suspects, fugitives, witnesses, victims of crime, or missing persons. We may disclose health information to a law enforcement official about a death we believe may be the result of criminal conduct, or about criminal conduct that may have occurred at our facility. We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure.

Specialized Government Functions

If you are in the military or a veteran, we will disclose your health information as required by command authorities. We may disclose health information to authorized federal officials for national security purposes, such as protecting the President of the United States or the conduct of authorized intelligence operations. We may disclose health information to make medical suitability determinations for Foreign Service.

Correctional Facilities

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official. We may release your health information for your health and safety, for the health and safety of others, or for the safety and security of the correctional institution.

Workers Compensation

We may disclose your health information as required by applicable workers compensation and similar laws.

Your Written Authorization

Other uses and disclosures of your health information not covered by this Notice, or the laws that govern us, will be made only with your written authorization. Most uses and disclosures of psychotherapy, marketing and the sale of protected health information requires your authorization. You may revoke your authorization in writing at any time, and we will discontinue future uses and disclosures of your health information for the reasons covered by your authorization. We are unable to take back any disclosures that were already made with your authorization, and we are required to retain the records of the care that we provided to you.

Your privacy rights regarding your health information

Right to Obtain a Copy of This Notice of Privacy Practices

We will post a copy of our current Notice in our facilities and on our website, caromonthealth.org. A copy of our current Notice will be available at our registration areas or upon request. To request a copy of our current Notice of Privacy Practices, please call 704.834.4843.

Right to See and Copy Your Health Record

You have the right to look at and receive a copy of your health record or your billing record. To do so, please contact the facility where you received treatment, or the Corporate Responsibility Office listed below. You may be required to make your request in writing. If you would like a copy of your health record, a fee may be charged for the cost of copying or mailing your record, as permitted by law. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.

Right to Update Your Health Record

If you believe that a piece of important information is missing from your health record, you have the right to request that we add an amendment to your record. Your request must be in writing, and it must contain the reason for your request. To submit your request, please contact the facility where you received treatment, or the Corporate Responsibility Office listed below. We may deny your request to amend your record if the information being amended was not created by us, if we believe that the information is already accurate and complete, or if the information is not contained in records that you would be permitted by law to see and copy. Even if we accept your amendment, we will not delete any information already in your records.

Right to Get a List of the Disclosures We Have Made

You have the right to request a list of the disclosures that we have made of your health information. The list will not contain disclosures from medical records that we have made for the purposes of treatment, payment and health care operations. It will not contain disclosures that were authorized by you, and certain other disclosures excluded by law. The list will not contain disclosures that were made before April 14, 2003. Your request must be in writing. To request a list of disclosures, please contact the facility where you received treatment, or the Corporate Responsibility Office listed below. The first list you request in a 12-month period is free. For additional lists, we may charge a fee, as permitted by law.

Right to Request a Restriction on Certain Uses or Disclosures

You have the right to request that we limit how we use and disclose your health information. We are legally required to accept certain requests to not disclose health information to your health plan for payment or healthcare operations purposes if you have paid in full out of your own pocket for the item or service. We are not legally required to accept any other request for a restriction, but we will consider your request. If we do accept it, we will comply with your request, except if you need emergency treatment. Your request must be in writing. To submit a request, please contact the facility where you received treatment, or the Corporate Responsibility Office listed below.

Right to Choose How You Receive Your Health Information

You have the right to request that we communicate with you in a certain way, such as by mail or fax, or at a certain location, such as a home address or post office box. We will try to honor your request if we reasonably can. Your request must be in writing, and it must specify how or where you wish to be contacted. To submit a request, please contact the facility where you received treatment, or the Corporate Responsibility Office listed below.

Notification of Breach of Unsecured Protected Health Information

CaroMont Health is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.

CONTACT PERSON

If you believe your privacy rights have been violated, you may file a complaint in writing with the contact person listed below. We will take no retaliatory action against you if you file a complaint about our privacy practices. If you would like to file a complaint with us or with the Secretary of the Department of Health and Human Services, please contact our Corporate Responsibility Office listed below. If you have questions about this Notice, or would like to exercise your Privacy Rights, please contact the facility where you received treatment, or contact our Corporate Responsibility Office:

CaroMont Health Corporate Responsibility Office
2525 Court Drive Gastonia, NC 28054
Corporate Responsibility Hotline: 1-877-785-0001
corporateresponsibility@caromonthealth.org

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you as well as any information we receive in the future.

Footnote: CaroMont Health System, located in Gastonia, North Carolina, includes CaroMont Regional Medical Center, Courtland Terrace, Gaston Hospice and CaroMont Medical Group. The mission of CaroMont Health is to provide exceptional healthcare to the communities we serve. In working to achieve this goal, it is the responsibility of each CaroMont Health workforce member to enforce its privacy policies and to take appropriate disciplinary or other actions for employee violations. Please note that for purposes of this Notice of Privacy Practices, CaroMont Health and its affiliate companies and all of its subsidiaries will be referred to collectively as "CaroMont Health." For privacy purposes only, CaroMont Health is organized as an Affiliated Covered Entity, as described in 45 CFR §164.504(d) (1); legally separate entities that are affiliated may designate themselves as a single covered entity.

Effective Date: 1/05/16