Our Pledge Regarding Health Information

We understand that information about you, your health, and your health care is personal. We are committed to protecting the security of that information, your protected health information (PHI), and to preventing its disclosure without your authorization, when required.

We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by this organization. This notice tells you about the ways in which we may use and disclose your PHI. We also describe your rights to the PHI that we keep about you and explain our obligations regarding the use and disclosure of your PHI.

We are required by law to:

• Make sure that health information that identifies you is kept private
• Provide you with this notice of our legal duties and privacy practices with respect to your PHI
• Follow the terms of the notice that is currently in effect
• Notify you if there is a security breach of protected health information (PHI) except when the PHI is encrypted or is disposed of securely

How We May Use and Disclose Your PHI

The following categories describe different ways that we use and disclose health information. Within each category, we have provided a list of examples.

For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to physicians, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices; at the hospital if you are hospitalized under our supervision; or at another physician’s office, lab, pharmacy, or other health care provider where we may have referred you for x-rays, laboratory tests, prescriptions, or other treatment purposes. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian at the hospital if you have diabetes so that we can arrange for appropriate meals. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

For Payment: We may use and disclose information about treatment and services we provided to you for billing purposes. The information may include monies that we have received from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so the plan will either pay us or reimburse you for the visit. We may also tell your health plan about a treatment before you receive it so that we can obtain prior approval, if required, or determine if your plan will cover the treatment. If we provide a service for which you pay in full out-of-pocket and you request that we not send PHI to your insurance company, we are obligated to comply with your request except when the information is needed to comply with the law.

For Health Care Operations: We may use and disclose protected health information about you for the operation of our organization. These uses and disclosures are necessary to run our office and to make sure that all our patients receive quality care. For example, we may use health information in a general review of our treatments and services or, more specifically, to evaluate the performance of our staff in caring for you. We may also combine the health information of many patients to decide what improvements we could make, what additional services we should offer, what services are not needed, or whether certain new treatments are effective. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning the individual identify of specific patients.

Health-Related Services and Treatment Alternatives: We may use and disclose protected health information (PHI) to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you.

Appointment Reminders: We may use and disclose protected health information to contact you as a reminder that you have an appointment or that you missed an appointment and should contact us to reschedule.

As Required by Law: We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans: If you are a member of the armed forces or separated or discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans’ Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose health information about you for public health activities. These activities generally include the following:

• The prevention or control of disease, injury, or disability
• The reporting of births and deaths
• The reporting of child abuse or neglect
• The reporting of reactions to medications or problems with products
• The notification of people about recalls of products they may be using
• The notification of a person or organization required to receive information on Food and Drug Administration–regulated products
• The notification of a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• The notification of the appropriate government authority, if we believe a patient has been the victim of abuse, neglect, or domestic violence (we will only make this disclosure if you agree or when required or authorized by law)

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do that by a law enforcement official:

• In reporting certain injuries, as required by law: gunshot wounds, burns, dog bites, and injuries to perpetrators of crime
• In response to a court order, subpoena, warrant, summons, or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person (name and address, date of birth or place of birth, social security number, blood type or Rh factor, type of injury, date and time of treatment and/or death, if applicable, and a description of distinguishing physical characteristics)
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at our facility
• In emergency circumstances to report a crime; the location of a crime or victims; or the identity, description, or location of a person who committed a crime

Coroners, Health Examiners, and Funeral Directors: We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons, or foreign heads of state.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Your Rights Regarding Health Information About You

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy health information such as medical and billing records that may be used to make decisions about your care.

In order to request inspection and copying of health information that may be used to make decisions about you, submit a written request to Plum Spring Clinic, 184 Lystra Estates Drive, Chapel Hill, NC 27517. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.

Right to Request Information in a Form of Your Choosing: You have the right to request the provision of protected health information (PHI) in a form of your choice such as paper or electronic. We will grant or deny the request within 30 days, and we may at times request a 30-day extension period. If any of the protected health information (PHI) is stored off-site, we will respond to your request within 60 days. We may charge you a reasonable, cost-based fee for preparing the information that you request.

Right to Request that We Send Information to Other Designated Parties: You have the right to request that we send copies of your protected health information (PHI) to other designated parties, provided that you submit a written signed request, designating the name, identity, and correct address of the designated recipient.

Right to Amend: If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing on the Request for Correction/Amendment of Protected Health Information form and submitted to Plum Spring Clinic, 184 Lystra Estates Drive, Chapel Hill, NC 27517. On the form you must include information supporting and the reasons for your request.

We may deny your request for an amendment if it is not in writing or does not include a reason for the request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
  • Is not part of the health information kept by or for our practice
  • Is not part of the information that you would be permitted to inspect and copy
  • Is accurate and complete

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures: You have the right to request a list of the disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to Plum Spring Clinic, 184 Lystra Estates Drive, Chapel Hill, NC 27517. Your request must state a time period that may not be longer than 6 years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in writing within 30 days of your request. If we are unable to provide you with this information within 30 days, we will notify you of that fact and inform you of the date by which we can supply the list. This date will not be more than 60 days from the date you made the request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we withhold your information from a specified nurse or that we not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively affect the care we provide you.

If we do agree, we will comply with your request, unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to Plum Spring Clinic, 184 Lystra Estates Drive, Chapel Hill, NC 27517 this office’s  to Request Restrictions on the Use and Disclosure of PHI form. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.

To request confidential communications, you must make your request in writing to Plum Spring Clinic, 184 Lystra Estates Drive, Chapel Hill, NC 27517 on the To Request Confidential Handling of Specified Health Information form. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish us to contact you.

Right to Request Withholding of Disclosures Health Plans: If you pay out-of-pocket in full for a service that we provide, you may request that we withhold from the payer disclosure of information on that service. We are obligated to comply with that request unless non-disclosure is required by law.

Right to Request Withholding of Use and Disclosure of Psychotherapy Notes: You may request that we withhold use and disclosure of psychotherapy notes related to care we provide for you.

Right to Be Notified Should there Be a Breach: You have the right to receive notice from us regarding a breach in disclosure of protected health information (PHI).

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from the office.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each of our sites and on our website. The notice will contain on the first page, at the top, the effective date. You may request a copy of our most current notice at any time.


If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services in Washington, DC. To file a complaint with us, complete our Patient Comment and Privacy Complaint Form. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information (PHI) about you for the reasons covered by your written authorization. We cannot revoke any disclosures that we have already made with your permission. We are required to retain our records of the care that we provided to you.

Acknowledgment of Receipt of This Notice

We will request that you sign a separate form acknowledging that you have received a copy of this notice.