The Southeastern Spine Institute Privacy Practices
NOTICE OF PRIVACY PRACTICES
As required by the Privacy Regulations created by Health Insurance Portability and Accountability Act
of 1996 (HIPAA),
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT
OF THIS PRACTICE) MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN
ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY
A. OUR COMMITMENT TO YOUR PRIVACY: Our practice is dedicated to maintaining the
privacy of your Protects Health Information (PHI). Protected Health Information is defined as
individually identifiable health information. In conducting our business, we will create records regarding
you and the treatment and services we provide you. We are required by law to maintain the
confidentiality of health information that identifies you. We are required by law to provide you with the
notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI.
By federal and state law, we must follow the terms of the notice of privacy practices that we have effect
at the time.
We must provide you with the following information:
– How we may use and disclose you PHI
– Your privacy rights regarding your PHI
– Our obligations concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI 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 that our practice had 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 of Privacy Practices in our office(s) in visible locations at
all time and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
The Southeastern Spine Institute
900 Bowman Road
Suite 300Mt. Pleasant, SC 29464
C. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:
1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have
laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis.
WE might use your PHI in order to write a prescription for you, or we might disclose your PHI to a
pharmacy when we order a prescription for you. Many of the people who work for our practice –
including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you
or to assist others in your treatments, Additionally, we may disclose your PHI to others who may assist
in your care, such as your spouse, children, or parents.
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the
services and items you may receive form us. For example, we may contact your health insurer to certify
that you are eligible for benefits (and for what range of benefits), and we may provide your insurance
with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.
We may also use and disclose your PHI to obtain payment form third parties that may be responsible for
such costs, such as family members. Also, we may use your PHI to bill you directly for services and
3. Health Care Operations. Our practice may use and disclose your PHI to operate our business. As
examples of the ways in which we may use and disclose your information for our operations, our
practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost management
and business planning activities for our practice.
4. Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind
you of an appointment.
5. Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment
options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of
health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our practice may release your PHI to a friend or family
member that is involved in your care, or who assists in taking care of you. For example, a parent or
guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In
this example, the babysitter may have access to this child’s medical information.
8. Disclosures Required by Law. Our practice will use and disclose your PHI when we are required to
do so by federal, state or local law.
D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable
1. Public Health Risks. Our practice may disclose your PHI to public health authorities that are
authorized by law to collect information for the purpose of:
– 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 the 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 is the patient agrees or we are required or authorized by law to disclose this
– notifying your employer under limited circumstance related primarily to workplace injury or
illness or medical surveillance
2. Health Oversight Activities. Our practice may disclose your PHI to a health oversight agency for
activities authorized by law. Oversight activities can include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures; or
other activities necessary for the government to monitor government programs, compliance with civil
rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a
court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also
disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party
involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested.
4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official: 1) regarding
a crime victim in certain situations, if we are unable to obtain person’s agreement. 2) concerning a death
we believe has resulted from criminal conduct. 3) regarding criminal conduct at our offices. 4) in
response to a warrant, summons, court order, subpoena or similar legal process. 5) to identify, locate a
suspect, material witness, fugitive or missing person. 6) In an emergency, to report a crime (including
the location of victim(s) of the crime, or the description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a
deceased individual or to identify the cause of death. If necessary, we may also release information in
order fro funeral directors to perform their jobs.
6. Research. Our practice may use and disclose your PHI for research purposes in certain limited
circumstances. We will obtain your written authorization to use your PHI for research purposes except
when: (a) our use or disclosure was approved by an Institutional Review Board or Privacy Board; (b) we
obtain the oral or written agreement of the researcher that (i) the information being sought is necessary
for the research study; (ii) the use or disclosure of your PHI is being used only for research and (iii) the
researcher will not remove any of your PHI from our practice; or (c) the PHI sought by the researcher
only related to descendants and the researcher agrees wither orally or in writing that the use or disclosure
is necessary for the research, and if we request it, to provide us with proof of death prior to access to the
PHI of descendants.
7. Serious Threats to Health or Safety. Our practice may use and disclose your PHI 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 prevent the threat.
8. Military. Our practice may disclose your PHI if you are a member of the U.S. or foreign military
forces (including veterans) and if required by the appropriate authorities.
9. National Security. Our practice may disclose your PHI to federal officials for intelligence and
national security activities authorized by law. We may also disclose your PHI to federal officials in order
to protect the President, other officials or foreign heads of state, or to conduct investigations.
10. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement
officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these
purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the
safety and security of the institution, and/or (c) to protect your health and safety, or the health and safety
of other individuals.
11. Worker’s Compensation. Our practice may release your PHI for worker’s compensation and
E. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about you:
1.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. For instance, 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 the Practice Manager 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.
2. Requesting Restrictions. You have the right to request the restriction in our use or disclosure of your
PHI for treatments, payment or health care operations. Additionally, you have the right to request that
we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment
The Southeastern Spine Institute Privacy Practices
for your care, such as family members and friend. 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 PHI, you must make your request in writing to The Practice Manager. Your
request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether
you are requesting to limit our practice’s use, disclosure or both; and (c) to whom you want the limits to
3. Inspection and Copies. You have the right too inspect and obtain a copy of the PHI 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 The Practice Manager in order to
inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. 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.
4. 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 The Practice
Manager. You must provide us with a reason that supports you 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 is you ask us to amend information that is in our opinion: (a: accurate
and complete; (b) not part of the PHI kept by and for our practice; (c) not part of the PHI which you
would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity
that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request and “accounting of
disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures that our practice
had made of your PHI for non-treatment or operations purposes. Use of your PHI as part of the routine
patient care in our practices is not required to be documented. For example, the doctor sharing
information with the nurse; or the billing department using your information to file your insurance
claim. In order to obtain for an accounting of disclosures, you must submit your request in writing to
The Practice Manager. All requests for an “accounting of disclosures” must state a time period, which
may not be longer than six (6) years form the date of disclosure and may not included dates before April
14, 2003. The first list you request within a 12-month period is free of charge, but our practice may
charge you for additional lists within the same 12-month period. Our practice will notify you of the costs
involved with additional requests, and you may withdraw your request before you incur any costs.
6. 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 The Practice Manager or our Front Desk personnel.
7. 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, To
The Southeastern Spine Institute Privacy Practices
file a complaint, contact The Practice Manager. All complaints must be submitted in writing. You will
not be penalized for filing a complaint.
8. Right to Provide and 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 your provide to us regarding use and disclosures or your PHI may be
revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose
your PHI for the reasons described in the authorization. Please note, we are required to retain records of
Again, if you have any questions, regarding this notice or our health information privacy policies,
please contact Our Practice Manager.
Effective Date: April 7, 2003