The Longleaf Neuro-Medical Treatment Center must collect timely and accurate health information about you and make that information available to members of your health care team in this facility, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside the Longleaf Neuro-Medical Treatment Center for services that this facility cannot provide. It is the legal duty of the Longleaf Neuro-Medical Treatment Center to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.

The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within the Longleaf Neuro-Medical Treatment Center as well as reasons why your health information could be sent to other service providers outside of this facility.

This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures the Longleaf Neuro-Medical Treatment Center uses to protect the privacy of your health information.

Please review this document carefully and ask for clarification if you do not understand any portion of it.

Resident/Personal Representative Acknowledgement

 

Resident Name:_________________________________

I have received the Longleaf Neuro-Medical Treatment Center’s Notice of Privacy Practices, which describes this facility’s methods for protecting the privacy of my health information that is used in providing health care services to me.

_______________________________________________/_________________________
Client (or Personal Representative)                                                 Date

The Longleaf Neuro-Medical Treatment Center is required by state and federal law to protect the privacy of your health information that may identify you. This health information includes mental health, developmental disability and/or substance abuse services that are provided to you, payment for those health care services, or other health care operations provided on your behalf.

The Longleaf Neuro-Medical Treatment Center is required by law to inform you of our legal duties and privacy practices with respect to your health information through this Notice of Privacy Practices. This Notice describes the ways we may share your past, present and future health information, ensuring that we use and/or disclose this information only as we have described in this Notice. We do, however, reserve the right to change our privacy practices and the terms of this Notice, and to make the new Notice provisions effective for all health information we maintain. Any changes to this Notice will be posted in our facility and on our facility web site at www.longleafneuromedical.ncdhhs.gov. Copies of any revised Notices will be available to you upon request.

If at any time, you have questions or concerns about the information in this Notice or about our facility’s privacy policies, procedures and practices, you may contact our facility Privacy Official at 252-399-2112 ext. 235

The Longleaf Neuro-Medical Treatment Center may use your health information, as needed, in order to provide, coordinate or manage your health care and related services. This includes sharing your health information with other health care providers within this agency.

Example: Your treatment team, composed of staff, such as doctors, nurses, and social workers, will need to review your treatment and discuss plans for your long-term care.

We will disclose your health information outside of the Longleaf Neuro-Medical Treatment Center only with your consent or when otherwise allowed under state or federal law.

The treatment provided to you will be shared with the Longleaf Neuro-Medical Treatment Center billing department so a bill can be prepared for services rendered. We may also share your health information with facility staff who review services provided to you to make certain you have received appropriate care and treatment. We will not disclose your health information outside of the Longleaf Neuro-Medical Treatment Center for billing purposes (i.e., bill your insurance company) without your consent except in certain situations when we need to determine if you are eligible for benefits such as Medicaid, Medicare or Social Security.

Example: The Reimbursement Officer may contact your local Department of Social Services to determine if you are currently eligible for Medicaid or if you would qualify for Medicaid.

Example: Our billing department will collect insurance and other financial information from you at the time of admission.

The Longleaf Neuro-Medical Treatment Center may use or disclose your health information in performing a variety of business activities that we call "health care operations". Some examples of how we may use or disclose your health information for health care operations are:

• Review the care you receive here and evaluating the performance of your treatment team to ensure you have received quality care.

• Review and evaluate the skills, qualifications and performance of health care providers who are taking care of you.

• Provide training programs for the Longleaf Neuro-Medical Treatment Center staff, students and volunteers.

• Cooperate with outside organizations that review and determine the quality of care that you receive.
• Provide information to professional organizations that evaluate, certify or license health care providers, staff or facilities, such as the Division of Facility Services.

• Allow the Longleaf Neuro-Medical Treatment Center attorney to use your health information when representing the Longleaf Neuro-Medical Treatment Center in legal matters.

• Resolve grievances within the Longleaf Neuro-Medical Treatment Center.
• Provide information to your internal client advocate who is available to represent your interests upon your request.

The Longleaf Neuro-Medical Treatment Center may disclose your health information for those circumstances that have been determined to be so important that your authorization may not be required. Prior to disclosing your health information, we will evaluate each request to ensure that only necessary information will be disclosed. Those circumstances include disclosures that are:

• Required by law;
  
• For public health activities. For example, we may disclose health information to public health authorities if you have a communicable disease and we have reason to believe, based upon information provided to us, that there is a public health risk such as evidence of your noncompliance with your treatment plan. If you suffer from a communicable disease such as tuberculosis or HIV/AIDS, information about your disease will be treated as confidential. Other than circumstances described to you in other sections of this Notice, we will not release any information about your communicable disease except as required to protect public health or the spread of a disease, or at the request of the State or Local Health Director;

• Regarding abuse, neglect or domestic violence;
• For health oversight activities such as licensing of nursing homes;

• For law enforcement purposes unless otherwise prohibited by state or federal law;
• For court proceedings such as court orders to appear in court;

• Related to death such as disclosure to a funeral director;

• Related to donation of organs or tissue;

• To avert a serious threat to the health or safety of a person or the public;

• Related to specialized government activities such as national security;

• To correctional institutions or other law enforcement officials when you are in their custody;

• For Workers’ Compensation in cases pending before the Industrial Commission;
• To your next of kin or other person involved in your care upon their request; however, information to be disclosed will be limited to admission, transfer, discharge, referrals and appointments and you will be notified of this request; and
• Related to medical research.

The Longleaf Neuro-Medical Treatment Center may contact you and/or legal responsible person for notification of room transfer;

Example: The Longleaf Neuro-Medical Treatment Center may call or send a letter to your Personal Representative concerning a change in your medical conditions.

• Make you and/or Personal Representative aware of alternative treatment, services, products or health care providers that may be of interest to you;

Example: If you are receiving treatment for a particular condition and your health care team learns of new or alternative treatments, we may contact you to inform you of such possibilities.

 

There are certain circumstances where we may disclose your health information and you have an opportunity to object. Such circumstances include:

• The professional responsible for your care may disclose your admission to or discharge from the Longleaf Neuro-Medical Treatment Center to your next of kin.
• Disclosure to public or private agencies providing disaster relief.

Example: We may share your health information with the American Red Cross following a major disaster such as a flood.

If you would like to object to our disclosure about your health information in either of the situations listed above, please contact our facility Privacy Official listed in this Notice for consideration of your objection.

The Longleaf Neuro-Medical Treatment Center will not disclose your health information without your authorization except as allowed or required by state or federal law. For all other disclosures, we will ask you to sign a written authorization that allows us to share or request your health information. Before you sign an authorization, you will be fully informed of the exact information you are authorizing to be disclosed/requested and to/from whom the information will be disclosed/requested.

You may request that your authorization be cancelled by informing the Longleaf Neuro-Medical Treatment Center Privacy Official that you do not want any additional health information about you exchanged with a particular person/agency. You will be asked to sign and date the Authorization Revocation section of your original authorization; however, verbal authorization is acceptable. Your authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time you cancelled your authorization are legal and binding.

You have the following rights regarding your health information as created and maintained by the Longleaf Neuro-Medical Treatment Center.

Right to receive a copy of this Notice

You have the right to receive a copy of Longleaf Neuro-Medical Treatment Center’s Notice of Privacy Practices. At your first treatment encounter with this facility, you will be given a copy of this Notice and asked to sign an acknowledgement that you have received it. In the event of emergency services, you will be provided the Notice as soon as possible after emergency services have been provided.

In addition, copies of this Notice have been posted in several public areas throughout the Longleaf Neuro-Medical Treatment Center, as well as on the Longleaf Neuro-Medical Treatment Center’s Internet web site at www.longleafneuromedical.ncdhhs.gov.  You have the right to request a paper copy of this Notice at any time from the Longleaf Neuro-Medical Treatment Center Social Work Department or the Longleaf Neuro-Medical Treatment Center Privacy Official.

Right to request different ways to communicate with you or Personal Representative

You have the right to request to be contacted at a different location or by a different method. For example, if you are the Personal Representative you may request that all written information from the Longleaf Neuro-Medical Treatment Center be sent to your work address rather than your home address. We will agree with your request as long as it is reasonable to do so; however, your request must be made in writing and forwarded to our the Longleaf Neuro-Medical Treatment Center Privacy Official.

Right to request to see and copy your health information

Whether you are a minor, incompetent adult or competent adult, you have the right to request to see and receive a copy of your health information in medical, billing and other records that are used to make decisions about you. Your request must be in writing and forwarded to the Longleaf Neuro-Medical Treatment Center Privacy Official. You can expect a response to your request within 30 days. If your request is approved, you may be charged a fee to cover the cost of the copy.

Your request may be denied by your physician or a professional designated by our facility director under certain circumstances. If we do deny your request, we will explain our reason for doing so in writing and describe any rights you may have to request a review of our denial. In addition, you have the right to contact our facility Privacy Official to request that a copy of your health information be sent to a physician or psychologist of your choice.

Whenever you have a personal representative who consented to your treatment, the personal representative has the same rights to request to see and copy your health information.

Right to request amendment of your health information

You have the right to request changes in your health information in medical, billing and other records used to make decisions about you. If you believe that we have information that is either inaccurate or incomplete, you may submit a request in writing to our agency Privacy Official and explain your reasons for the amendment. We must respond to your request within 30 days of receiving your request. If we accept your request to change your health information, we will add your amendment but will not destroy the original record. In addition, we will make reasonable efforts to inform others of the changes, including persons you name who have received your health information and who need the changes.

We may deny your request if:

• The information was not created by the Longleaf Neuro-Medical Treatment Center (unless you prove the creator of the information is no longer available to change the information);
• The information is not part of the records used to make decisions about you;
• We believe the information is correct and complete; or
• Your request for access to the information is denied.

If we deny your request to change your health information, we will explain to you in writing the reasons for denial and describe your rights to give us a written statement disagreeing with the denial. If you provide a written statement, the statement will become a permanent part of your record. Whenever disclosures are made of the information in question, your written statement will be disclosed as well.

Right to request a listing of disclosures we have made

You have a right to a written list of disclosures of your health information. The list will be maintained for at least six years for any disclosures made after April 14, 2003. This listing will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed and the purpose of the disclosure.

The Longleaf Neuro-Medical Treatment Center is not required to include the following on the list of disclosures:

• Disclosure for your treatment;

• Disclosure for billing and collection of payment for your treatment;

• Disclosures related to our health care operations;

• Disclosures that you authorized;
• Disclosures to law enforcement when you are in their custody; or
• Disclosures made to individuals involved in your care.

Your first request for a listing of disclosures will be provided to you free of charge. However, if you request a listing of disclosures more than once in a 12 month period, you may be charged a reasonable fee. We will inform you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.

Right to request restrictions on uses and disclosures of your health information

You have the right to request that we limit our use and disclosure of your health information for treatment, payment and health care operations. You also have the right to request a limit on the health information we disclose about you to your next of kin or someone who is involved in your care. ( Example: you could ask that we not disclose information about your family history of heart disease.) We will provide you with a form to document your request.

We will make every attempt to honor your request but are not required to agree to such request. However, if we do agree, we must follow the agreed upon restriction (unless the information is necessary for emergency treatment or unless it is a disclosure to the U.S. Secretary of the Department of Health and Human Services).

You may cancel the restrictions at any time and we will ask that your request be in writing. In addition, the Longleaf Neuro-Medical Treatment Center may cancel a restriction at any time, as long as we notify you of the cancellation.

If you believe we have violated your privacy rights, or if you want to file a complaint regarding our privacy practices, you may contact our facility Privacy Official. Contact information is as follows:

Longleaf Neuro-Medical Treatment Center Privacy Official
4761 Ward Blvd, Wilson, NC 27893
252-399-2112 ext. 235
252-399-2132
linda.taylor@ncmail.net

The North Carolina Department of Health and Human Services operates an information and referral service located in the Office of Citizen Services, known as CARE-LINE, which has been designated to receive and document complaints and concerns regarding your privacy. Contact information is as follows:

CARE-LINE
2012 Mail Service Center
Raleigh, NC 27699-2012

Voice Phone (English and Spanish):

1-800-662-7030 (Toll Free)

(919) 733-4261 (Triangle Area and Out of State)

FAX: (919) 715-8174

TTY: 1-877-452-2514 (TTY Dedicated)

(919) 733-4851 (TTY Dedicated for local or out of state calls)

Email: care.line@ncmail.net

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact information is as follows:

Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909

Voice Phone: (404) 562-7886
FAX: (404) 562-7881
TDD: (404) 331-2867

If you file a complaint, we will not take any action against you or change the quality of health care services we provide to you in any way.

Primary Federal and State laws and regulations that protect the privacy of your health information are listed below.

Confidentiality of Alcohol and Drug Abuse Patient Records – 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations.

Health Insurance Portability and Accountability Act (HIPAA), Administrative Simplification, Privacy of Individually Identifiable Health Information – 42 U.S.C. 1320d-1329d-8 and 42 U.S.C. 1320d-2(note) for Federal laws and 45 CFR Parts 160 and 164 for Federal regulations.

NC General Statutes – Chapter 122C, Article 3 (Client’s Rights and Advance Instruction), Part 1 (Client’s Rights). Chapter 90 (Medicine and Allied Occupations), Article 1 (Practice of Medicine).

NC Administrative Code – 10 NCAC 18 D (Confidentiality Rules).