NOTICE OF PRIVACY PRACTICES
Notice to individuals receiving services from The Arc of Orange County about how your medical information is protected, used, and disclosed. Please review this carefully.
All individual and family information provided during screening, admission, and treatment / habilitation process is considered confidential by the employees, interns, and volunteers of The Arc of Orange County. The disclosure of Protected Health Information (PHI) is governed by North Carolina General Statute 122C, federal law regarding substance abuse records 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as any other applicable federal or state laws.
Exchange and use of PHI between The Arc of Orange County staff for the purpose, treatment, payment, or healthcare operations will be permitted and based on “need to know” guidelines, and positional authority.
Disclosure of PHI outside The Arc of Orange County is permitted when you or your legal representative signs a written authorization, or when you give you verbal authorization in an emergency situation. Any authorization for disclosure may be revoked at any time, except to the extent that action has been taken in reliance on it.
You have the right to request restriction of the disclosure of your PHI, except when The Arc of Orange County is required to do so. Under the following specific conditions, disclosure of information outside The Arc of Orange County is permitted / required by law and professional ethics without your specific authorization:
- When there is a medical or psychiatric emergency involving the health / safety of others
- When The Arc of Orange County’s staff, interns, or volunteers are required by law to report instances of neglect or abuse of a child or disabled adult.
- When The Arc of Orange County is responding to a court order.
- When The Arc of Orange County is required by North Carolina Administrative Code to disclose physician information due to an incident which would cause health risk to other persons.
- When The Arc of Orange County’s Board of Directors authorizes research for the purpose of programmatic planning and evaluation of services through the use of statistical datum / data that cannot be linked to any individual.
You also have other rights related to the use and disclosure of PHI in your medical record. These include:
- Right to request your medical record be designated as a “secure” file
- Right to inspect and request a copy of your medical record
- Right to request amendment of any section of your medical record
- Right to receive an accounting of disclosures that have occurred with your medical record
If you are interested in learning more about any of the rights identified on this document, please contact one of The Arc of Orange County’s Privacy Officers:
- Christian Keller - (919) 942-5119 ext. 118
- Duffy Palmer - (919) 942-5119 ext. 114
Each disclosure of PHI will be documented in the medical record. You have the right to request an accounting of these disclosures. The Arc of Orange County uses computerized records to meet statistical, financial, and medical record requirements. The Arc of Orange County will comply with expected forms for security of electronic records and will make every effort to secure any identifying information transmitted outside of this organization.
The Arc of Orange County may mail or email information to you regarding appointment reminders, billing information, or other information about treatment alternatives, or services that might be of interest to you. If you no longer wish to receive office mailings from The Arc of Orange County’s office, you may notify the office of their wishes.
The Arc of Orange County reserves the right to change this notice and to make the new notice effective for all PHI maintained in hard copy or electronic format. Revisions to the NOTICE OF PRIVACY PRACTICES will be made available at The Arc of Orange County’s office for distribution to all individuals receiving services and their families.
The Arc of Orange County recognizes the importance of confidentiality, and your right to be fully informed of all regulations regarding PHI. If you feel your privacy rights have been violated, you may contact the Secretary of The North Carolina Department of Health and Human Services (DHHS) at 2001 Mail Service Center, Raleigh, NC 27699-2001, or 919.733.4534; or the United States Secretary of Health and Human Services, at 200 Independence Ave. SW, Washington, DC 20201, or 877.696.6775. Provision of services will not be affected by the filing of any complaint.
I have read, and understand my privacy rights at The Arc of Orange County.
Print Name: _________________________________________________________________
First Name MI Last Name
Signature: ___________________________________________________________________
Date
Arc Representative: ___________________________________________________________
Date
