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Privacy Notice

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.

I.          How Sampson Regional Medical Center Medical Center May Use or Disclose Your Health Information 

Federal law requires Sampson Regional Medical Center to maintain the privacy of individually identifiable health information and to provide you with notice of its legal duties and privacy practices with respect to such information.  Sampson Regional Medical Center must abide by the terms and conditions of this Privacy Notice, as revised from time to time.

A.        USES OR DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT & HEALTH CARE OPERATIONS

Sampson Regional Medical Center may use your individually identifiable health information for treatment, payment and health care operations.  Examples of treatment, payment and health care operations include:

“Treatment” could include consulting with or referring your case to another health care provider.  The type of health information that Sampson Regional Medical Center could use or disclose includes, but is not limited to such health conditions as blood type, diagnosis of your condition or pregnancy status.  Sampson Regional Medical Center may use or disclose your individually identifiable health information for its own provision of treatment or may disclose such information for the treatment activities of another health care provider.

“Payment” could include Sampson Regional Medical Center’s efforts to obtain reimbursement from you or a responsible third party for services that Sampson Regional Medical Center has provided to you.  Sampson Regional Medical Center may use or disclose your individually identifiable information for its own payment or for the payment and activities of another health care provider or health plan or health care clearinghouse.

“Health care operations” could include activities such as quality assessment and improvement activities and audits of the process of billing you or a third party for health care services Sampson Regional Medical Center provides to you.  As part of Sampson Regional Medical Center’s treatment of you and its operations, Sampson Regional Medical Center may contact you, by phone or by mail, to provide appointment reminders or to provide information about treatment alternatives or other health-related services that may be of interest to you.  Sampson Regional Medial Center may also contact you for fundraising purposes.  Sampson Regional Medical Center may use or disclose your individually identifiable health information for its own health care operations or for limited health care operations of a health plan, health care clearinghouse, or health care provider that is subject to certain federal health information privacy laws.  The entity, which receives this information, must have or have had a treatment relationship with you and the information we disclose must pertain to that relationship.  Limited health care operations include various quality assessment and improvement activities, credentialing and training activities, and health care fraud and abuse detection or compliance activities.  

B.        USES OR DISCLOSURES SAMPSON REGIONAL MEDICAL CENTER MAY MAKE WITHOUT YOUR AUTHORIZATION

In addition to treatment, payment and health care operations, and unless this Privacy Notice recites a more stringent restriction in Section C the law permits and requires Sampson Regional Medical Center to make, use and/or disclose individually identifiable health information without your written authorization:  (i) for certain public health activities and purposes, including reporting of adverse product event to the Food and Drug Administration, (ii) to report suspected abuse, neglect or domestic violence, (iii) to submit information to health oversight agencies for oversight activities, such as audits, authorized by law, (iv) in the course of judicial and administrative proceedings, (v) for law enforcement purposes, (vi) to a medical examiner, coroner or funeral director, (vii) to assist an organ procurement organization or organ bank in facilitating organ or tissue donation and transplantation, (viii) to further research, provided that Sampson Regional Medical Center complies with federal requirements, (ix) to avert a serious and imminent threat to public health safety, (x) for specialized government functions, including activities related to the military, veterans, or national security, (xi) to comply with workers’ compensation or similar laws.  Sampson Regional Medical Center will make the above uses and/or disclosures of information in accordance with applicable law.

In addition, Sampson Regional Medical Center may use and/or disclose your individually identifiable health information as follows:

Business associates:  There are some services provided in Sampson Regional Medical Center through contracts with business associates which are vendors, professionals and others who perform some treatment, payment or health care operations function on behalf of Sampson Regional Medical Center or who otherwise provide services and have access to or use your protected health information.  Examples include physician services in the emergency department and radiology, certain laboratory tests, and a certain copy service we use when making copies of your health record.  When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have 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 by requiring that they enter into an appropriate agreement with Sampson Regional Medical Center.   

Directory:  Unless you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes.  This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.  If you are unable to object, we may use and disclose this information consistent with your prior expressed preference, if known, and the health professional’s judgment.

Notification:  Unless you object, health professionals, using their best judgment, may use or disclose information to notify or assist in notifying a family member, personal representative, or any person responsible for your care, location, and general condition.  If you are unable to object, we may exercise our professional judgment to determine if a disclosure is in your best interest and disclose only information that is directly relevant to the person’s involvement with your health care.

Communication and Family: Unless you object, health professionals, using their best judgment, may use or disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.  If you are unable to object, we may exercise our professional judgment to determine if a disclosure is in your best interest and disclose only information that is directly relevant to the person’s involvement with your health care.

Disaster Relief:  We may use or disclose information for disaster relief purposes.

Incidental Uses and Disclosures:  We are permitted to use and disclose information incident to another use or disclosure of your protected health information permitted or required under law.

Limited Data Sets:  We may use or disclose a limited data set (i.e., in which certain identifying information has been removed) of your protected health information for purposes of research, public health, or health care operations.  Any recipient of that limited data set must agree to appropriately safeguard your information.

C.        MORE STRINGENT PROTECTION FOR YOUR HEALTH INFORMATION  

In certain cases, North Carolina law provides more stringent privacy protections of your health information than this Privacy Notice recites above.  Specifically, the following:

If you are a patient with AIDS or HIV infection or a communicable disease or condition subject to public health reporting requirements, Sampson Regional Medical Center will only disclose information regarding your AIDS, HIV or communicable disease status with your written permission except (i) if you cannot be identified from the information, (ii) as disclosure is required or permitted under communicable disease law or laws specifically authorizing or requiring disclosure of AIDS information or records, (iii) if a subpoena or court order requires disclosure, or (iv) if release is necessary to protect public health.  If Sampson Regional Medical Center reveals your information for treatment, payment or health care operations purposes, or for any other reason, then you must sign a different permission form.

If you are an adult care home patient, your personal and medical records may not be disclosed by the adult care home without your written release unless disclosure is required by law.  The written release must specify to whom the disclosure may be made except if disclosure is:  (a) for the purposes of payment, treatment or health care operations and is to pay those contracted with the adult care home (and the contract requires disclosure), (b) to the treating physician, or (c) to agencies/institutions/individuals providing emergency medical services.  You may object in writing to a treating physician’s access to your medical records and the adult care home may not refuse to abide by such objection. 

If you are a nursing home patient, then the nursing home will not reveal your confidential information to anyone, unless you give permission in writing.  If the nursing home discloses information for any purpose, you must sign a permission form.  However, please note that the nursing home may reveal the information without your written consent if the law requires the nursing home to do so or if the communication is to family members, provided that you do not object, or in other limited circumstances.

If you provide confidential information to a social worker, the social worker will not reveal that information to anyone unless you give permission in writing.  If the social worker reveals your information for any purpose, then you must sign a permission form.  However, please note that the social worker may reveal information you have given to the social worker without your written permission if the law requires the social worker to do so or if not revealing the information may present a clear and imminent danger to you or others.

If you provide personal information to an optometrist, then the optometrist will not reveal that information to anyone, unless you give permission in writing.  If the optometrist reveals your information for any purpose, then you must sign a permission form.  However, please note the optometrist may reveal the information without your written permission if the law requires the optometrist to disclose the information.

If you provide confidential information to a substance abuse professional, then the substance abuse professional will not reveal that information to anyone, unless you give permission in writing.  If the substance abuse professional reveals your information for any purpose, then you must sign a permission form.  However, please note that the substance abuse professional may reveal the information without your written permission if there is a clear and imminent danger to you or to others; in a medical emergency, but then only to an appropriate professional or to public authorities; or, when the law requires the substance abuse professional to disclose the information.

If you provide confidential information to a bodywork therapist, then the bodywork therapist will not reveal that information to anyone, unless you give permission in writing.  If the bodywork therapist reveals your information for any purpose, then you must sign a permission form.  However, the bodywork therapist may reveal the information without your written permission if the law or a court order may require the therapist to disclose the information.

For adult day and adult day health program patients, Sampson Regional Medical Center will not disclose confidential information to anyone unless you name a person in writing.  You will need to provide Sampson Regional Medical Center with written permission to disclose your confidential information each time Sampson Regional Medical Center needs to disclose the information, unless the law requires Sampson Regional Medical Center to disclose the information.

If you are seeking treatment and rehabilitation for drug dependence, Sampson Regional Medical Center will not reveal your name to law enforcement officers or agencies, unless you provide us with written permission.  Sampson Regional Medical Center will also not reveal your name in any court, grand jury or administrative proceeding without your written permission, unless the law compels Sampson Regional Medical Center to reveal your name.  

For patients of nursing home facilities, home health care, ambulatory surgery facilities, nursing pool facilities, Sampson Regional Medical Center’s cardiac rehabilitation program and hospice, you have the right to object in writing to Sampson Regional Medical Center’s disclosing your individually identifiable health information to the North Carolina Department of Health and Human Services during an inspection.

If you are an unemancipated minor under North Carolina law, then Sampson Regional Medical Center physicians will not disclose, without your consent, information related to your health status regarding treatment for venereal disease, pregnancy (except in the case of an abortion), abuse of drugs or alcohol or emotional disturbance to a parent, legal guardian, person standing in loco parentis or a legal custodian who has legal authority to provide permission for your medical or psychiatric care.  However, the physician may notify these individuals if in the physician’s opinion the notification is essential to your life or health.  In addition, the physician may give such information if your parent, legal guardian, person standing in loco parentis or legal custodian contacts the physician concerning your treatment.

For patients receiving mental health, developmentally disabled or substance abuse services:

  • Except as described in these paragraphs, Sampson Regional Medical Center may only use or disclose your confidential information if you give our written permission or sign an authorization that specifies the name of the persons to whom Sampson Regional Medical Center may disclose the information.  Your written permission or authorization must also state the specific time period during which the release is valid.
     
  • If a court has adjudicated you incompetent or you are a minor, Sampson Regional Medical Center will not disclose your health information to a person acting as an external client advocate on your behalf, unless both you and your legally responsible person have executed a written permission or authorization. 
     
  • Sampson Regional Medical Center may also disclose your health information, without your permission or authorization, in the following circumstances:  (i) to other health care providers treating you, as necessary to meet an emergency, provided that we attempt to obtain your permission after the emergency; (ii) to health oversight agencies for oversight activities (e.g., audits); (iii) to internal client advocates to monitor services that Sampson Regional Medical Center is providing to you and to serve as an advocate; (iv) to provide law enforcement agencies and other persons with information regarding your escape from, breach of condition of release from and/or return to a 24-hour facility, in order to assure your expeditious return and protect the public; (v) to an attorney, upon your request, or to your personal representative; (vi) to comply with the provisions of a court order; (vii) to the court, certain attorneys and/or other interested parties in connection with certain legal proceedings (including involuntary commitment, guardianship, criminal cases, and others) where your confidential information is relevant to the proceeding; (viii) in some circumstances, to attorneys representing Sampson Regional Medical Center or its employees; (ix) as the law requires, including laws requiring reporting of abuse or neglect; (x) to a correctional institute to facilitate our treatment; (xi) to avert an imminent and serious threat to the health or safety of yourself or another individual; (xii) to business associates who perform service for Sampson Regional Medical Center  and who have a contract with Sampson Regional Medical Center that prohibits the business associate from further disclosing the information; (xiii) in certain cases, limited information, such as the act of admission or discharge, certain transfers, decision to leave against medical advice, referral and appointment information for treatment after discharge to certain individuals you designate, your next of kin, and/or certain other family members, to provide them with basic information related to your treatment.  Sampson Regional Medical Center will not disclose more detailed information about your treatment to these individuals (e.g., diagnosis, prognosis, medications prescribed, dosage, side effects, progress and additional information), unless you have given your permission or authorization.  However, please note that Sampson Regional Medical Center can disclose your health information to these individuals only if your health care professional deems the disclosure to be therapeutically beneficial to you.     

NOTE:  References in this Privacy Notice to health care professionals include only those professionals that Sampson Regional Medical Center employs.

D.          MARKETING

We will need your written authorization to use and disclose your PHI for marketing purposes, except if the marketing is a face-to-face communication or if it involves a promotional gift of nominal value.  “Marketing” includes a communication about a product or service that encourages your to purchase or use the product or service.  It also includes an arrangement whereby Sampson Regional Medical Center discloses your PHI to another entity; in exchange for compensation, and the other entity communicate about its own product or service to encourage purchase or use of that product or service.  Marketing does not include our describing a health-related product or service (or payment for such product or service) that we provide.  Marketing also does not include our communication for your treatment, or to direct or recommend to you alternative treatments, therapies, health care providers, or settings of care.

E.        NO OTHER USES OR DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION 

Sampson Regional Medical Center may not make any other uses and disclosures of your individually identifiable health information without your written authorization.  You may revoke your authorization at any time if you provide written notice to Sampson Regional Medical Center.

II.         YOUR RIGHTS

Federal and state law protect your right to keep your individually identifiable health information private.

Your Right to Receive Confidential Communications and to Request Restrictions.

You may request that you receive communications from Sampson Regional Medical Center regarding individually identifiable health information by alternative means or at alternative locations.  You must make your request for confidential communications in writing and must submit this request to the office listed below.  Sampson Regional Medical Center reserves the right to condition your request on the receipt of information regarding how you wish Sampson Regional Medical Center to handle payment and/or on the availability of an alternative address or method of contact that you may request.  You may request other restrictions on certain uses and disclosures of protected health information for purposes of treatment payment, and health care operations; however, the law does not require Sampson Regional Medical Center to agree to the requested restrictions unless the restriction request is a reasonable restriction of communication.

Your Right to Inspect and Copy.

You have the right to inspect and obtain a copy of any individually identifiable health information in your medical record unless our attending physician has determined that there is a sound medical reason to deny you access or unless the law restricts Sampson Regional Medical from disseminating the information.

Your Right to Amend. You also have the right to amend your individually identifiable health information, unless Sampson Regional Medical Center did not create such information or unless Sampson Regional Medical Center determines that your medical record is accurate and complete in its existing form.

Your Right to an Accounting. 

You have the right to request and receive an accounting of disclosures of your individually identifiable health information that Sampson Regional Medical Center has made in either the six (6) years prior to the request date, or during the period between the request date and the date that federal law required Sampson Regional Medical Center to comply with federal privacy regulations, whichever is more recent.  Such an accounting may not include disclosures made to carry out treatment, payment or health care operations, to create an accurate patient directory or notify persons involved in your care, to ensure national security, to comply with the authorized requests of law enforcement, to inform you of the content of your medical records, or those disclosures which you have previously authorized pursuant to a validly executed authorization form.

If you would like more information on how to exercise these rights, please contact Sampson Regional Medical Center’s Chief Privacy Officer, Monica Lytle at 910-590-8795.

A.        The Right to Get This Notice by E-Mail.

You have the right to get a copy of this notice by e-mail.  Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of this notice.

III.        GRIEVANCES OR FURTHER INQUIRES

If you believe that Sampson Regional Medical Center has violated your privacy rights with respect to individually identifiable health information, you may file a complaint with Sampson Regional Medical Center and the Department of Health and Human Services.  To file a complaint with Sampson Regional Medical Center, please contact Monica Lytle at 910-590-8795.  Sampson Regional Medical Center will not retaliate against you for filing a complaint.  You may also contact the above office for a copy of this Privacy Notice or for further information regarding its contents. 

IV.       AMENDMENTS

Sampson Regional Medical Center reserves the right to amend the terms of this Privacy Notice at any time and to apply the revised Privacy Notice to all individually identifiable health information that it maintains.  If Sampson Regional Medical Center amends this Privacy Notice, you will be provided with a revised copy at your next visit to Sampson Regional Medical Center, or upon your request.  The revised Privacy Notice will also be available on Sampson Regional Medical Center’s web site, (www.sampsonrmc.org).