Patient Privacy

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This notice becomes effective 4/14/03



The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.


Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). We understand that your health information is personal, and we are committed to protecting it. In order to provide you quality care & comply with legal requirements, we must create a record of the care and services that we provide to you. This notice describes the ways in which we may use and share information about you. It also describes your rights and the duties that we have regarding the use and disclosure of your IIHI. Part of our duty is to provide you with this notice of our legal duties and the privacy practices that we maintain. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:


Kristin Fisher, RN
HIPAA Privacy Officer
4414 Lake Boone Trail, Suite 502
Raleigh, NC 27607
(ph) 875-0539 ext.222

  2. Treatment.Our staff & providers may use your IIHI to evaluate your health, diagnose medical conditions, and provide treatment to you. Examples:
  • We may order laboratory tests and use the results to help diagnose.
  • We might use your IIHI in order to write a prescription for you.
  • We might disclose your IIHI to a pharmacy when ordering a prescription.
  • Managed Care Referrals/Authorizations
  • We may also disclose your IIHI to other health care providers for purposes related to your treatment.
  1. Payment.Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. Examples:
  • Contacting your health insurer to verify your eligibility & benefits.
  • Providing your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment
  • Disclosing your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members
  • Billing you directly for services and items
  • We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.
  1. Health Care Operations.Our practice may use and disclose your IIHI to support the day-to-day activities & management of Raleigh Family Practice, P.A. Examples:
  • Evaluating the quality of care you received from us
  • Conducting cost-management and business planning activities
  • Obtaining accreditation, certificates, licenses & credentials
  2. Appointment Reminders.Our practice makes reminder calls for upcoming appointments. If you are unavailable, we will leave a message on voicemail, answering machine, or with the person who answers your home phone. Information regarding the nature of your visit will not be disclosed.
  3. Health-Related Benefits and Services.Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you. Examples:
  • Notification by mail/phone of new services that we provide.
  • We may notify you of classes or informational sessions held by our facility that may relate to your health.
  1. Release of Information to Family/Friends.Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you if we are given authorization to do so. Examples:
  • A parent or guardian may ask that a babysitter take their child to the doctor, the babysitter may have access to this child?s medical information.
  • An adult child may be involved in the care of an elderly parent.
  1. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES.The following categories describe unique scenarios in which we may use or disclose your identifiable health information when required by law:
  2. Disclosures Required By Law.Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.
  3. Public Health Risks.Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of: Examples:
  • maintaining vital records, such as births and deaths
  • reporting child abuse or neglect
  • preventing or controlling disease, injury or disability
  • notifying a person regarding potential exposure to a communicable disease
  • notifying a person regarding a potential risk for spreading or contracting a disease or condition
  • reporting reactions to drugs or problems with products or devices notifying individuals if a product or device they may be using has been recalled
  • notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
  • notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
  1. Health Oversight Activities.Our practice may disclose your IIHI to a healthcare oversight agency for activities authorized by law. Examples:
  • Investigations/Disciplinary Actions
  • Inspections/Audits/Licensure
  • Surveys
  • Civil, administrative, and criminal procedures or actions
  • Activities necessary for the government to monitor government programs.
  1. Lawsuits and Similar Proceedings.Our practice may use and disclose your IIHI if you are involved in a lawsuit or similar proceeding. Examples:
  • In response to a court or administrative order.
  • In response to a discovery request
  • In response to subpoena
  • Other lawful process by another party involved in the dispute

We will make every effort to inform you of the request prior to disclosing the information the party has requested.

  1. Law Enforcement.We may release IIHI if asked to do so by a law enforcement official: Examples:
  • Regarding a crime victim in certain situations, if we are unable to obtain the person?s agreement
  • Concerning a death we believe has resulted from criminal conduct
  • Regarding criminal conduct at our offices
  • In response to a warrant, summons, court order, subpoena or similar legal process
  • To identify/locate a suspect, material witness, fugitive or missing person
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
  1. Deceased Patients.Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
  2. Serious Threats to Health or Safety.Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  3. Military.Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) if required by the appropriate authorities.
  4. National Security.Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
  5. Inmates.Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Examples:
  • For the institution to provide health care services to you.
  • For the safety and security of the institution
  • To protect your health and safety or the health and safety of other individuals.
    You have the following rights regarding the IIHI that we maintain about you:
  2. Confidential Communications.You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Example:
  • You may ask that we contact you at home, rather than work.

In order to request a type of confidential communication, you must make a written request to our privacy officer specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

  1. Requesting Restrictions.You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends.

We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to our privacy officer. Your request must describe in a clear and concise fashion:

  • The information you wish restricted
  • Whether you are requesting to limit our practice?s use, disclosure or both
  • To whom you want the limits to apply
  1. Inspection and Copies.You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes.

You must submit your request in writing to our privacy officer in order to inspect and/or obtain a copy of your IIHI.

If you would like to inspect your records, you must schedule an appointment with the privacy officer. There is a fee of $25.00 for the time associated with this process.

Our practice is contracted with Smart Corporation to make copies of medical records. Smart Corporation will invoice you for their services. Urgent requests for medical records will be handled by our office. The charges are as follows: .75 per page for pages 1-25, .50 per page for pages 26-100, and .25 per page for each additional page with a minimum fee of $10.00

Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

  1. Amendment.You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice.

To request an amendment, your request must be made in writing and submitted to our privacy officer. You must provide us with a reason that supports your request for amendment.

Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion:

  • Accurate and complete
  • Not part of the IIHI kept by or for the practice
  • Not part of the IIHI which you would be permitted to inspect and copy
  • Not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  1. Accounting of Disclosures.All of our patients have the right to request an ?accounting of disclosures.? An ?accounting of disclosures? is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of treatment, payment or healthcare operations is not required to be documented.

To obtain an accounting of disclosures, you must submit your request in writing to our privacy officer. All requests for an ?accounting of disclosures? must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003.

The first list you request within a 12-month period is free of charge. Our practice will charge $5.00 for additional lists within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

  1. Right to a Paper Copy of This Notice.You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our privacy officer.
  2. Right to File a Complaint.If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services (DHHS). All complaints must be submitted in writing.You will not be penalized for filing a complaint.

To file a complaint with our practice, contact our privacy officer.

To file a complaint with DHHS, contact them directly.

  1. Right to Provide an Authorization for Other Uses and Disclosures.Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization.


Kristin Fisher, RN
Raleigh Family Practice, P.A.
HIPAA Privacy Officer
4414 Lake Boone Trail, Suite 502
Raleigh, NC 27607

(919) 875-0539 ext.222