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This notice describes how medical information about you may be used and disclosed and how you can gain access to this information.


The goal of Piedmont Health Services and Sickle Cell Agency is to take appropriate steps to protect the confidentiality of medical information at this agency.  We are required to: a) maintain the privacy of medical information provided to us; b) provide notice of our legal duties and privacy practices; and c) abide by the terms of the Notice of Privacy Practices currently in effect.  New federal legislation requires that we issue this official notice of our privacy practices.



Any health care professional authorized to enter information into your medical record, all employees, staff and other personnel at this Agency who may need access to your information must abide by this notice.  All partners, business associates, subsidiaries, (e.g. a billing service, third party payment services), sites and locations of this agency may share medical information with each other for treatment, payment purposes or health care operations described in this notice.


This agency will need to collect certain data or personal information from you in order to provide any form of service for you.

  • Your name, address, and phone number

  • Information about immediate family members

  • Information relating to your medical history

  • Your insurance information and medical coverage

  • Information concerning your doctor, laboratory reports, nurse or other medical providers.

  • Your medical history

In the process of collecting certain medical information about you, a medical record of the care will be maintained by this agency.



The following categories describe different ways that we may use and disclose medical information without your specific consent or authorization.  Examples are provided for each category of uses or disclosures. Not all possible disclosures are listed.

For Treatment: We may share medical information about you with other agencies or business associates as outlined in this information in order to coordinate your medical care. 

For Payment Sources: We may use and disclose medical information about you so that the treatment and services you receive from other partnering agencies or business associates may be billed and payment may be collected from you, an insurance company or a third party.  Other identifying or personal information may also be collected from you in the process of certifying you for medical insurance coverage through this program. 

For Health Care Operations: We may use and disclose medical information about you for health care operations to assure that you receive quality care.  For example, we sometimes arrange or may be required to have services audited by accreditation organizations or have other consultants come into our practice to evaluate our operation, and tell us how to improve services.

Other Uses or Disclosures That Can Be Made Without Your Consent or Authorization


  • As required during an investigation by law enforcement agencies; a warrant, subpoena, or other court or administrative hearing body

  • To avert a serious threat to public safety

  • As required by military command authorities for their medical records

  • To workers’ compensation or similar programs for processing of claims

  • In response to a legal proceeding

  • To a coroner or medical examiner for identification of a body

  • If an inmate, to the correctional institution or law enforcement official

  • As required by the US Food and Drug Administration (FDA)

  • Other healthcare providers’ treatment activities

  • Other covered entities and providers’ payment activities

  • Other covered entities healthcare operation activities (to the extent permitted under HIPAA)

  • Uses and disclosures required by law

  • Uses and disclosures in domestic violence or neglect or child abuse situations

  • Disclosure of protected health information for national security and intelligence activities for the protection of heads of state.


Our Business Associates:  We sometimes work with outside individuals and other similar agencies in an attempt to provide successful services to you. We may disclose your health information to these business associates so that they can perform the tasks that we contract with them to do. Our business associates agree to not use or disclose Protected Health information other than as permitted or required by the Agreement or as Required By Law.


Individuals involved in your care or payment for your care: We may disclose information to individuals involved in your care or in the payment for your care, but we will obtain your agreement before doing so.  This includes people and organizations that are included in coordinating your care, such as your spouse, your parents, your doctors, or home health personnel providing services to you.  As a provider of care to you, we must speak with your primary physician or other health care providers, you can let us know if we should not speak with other individuals, such as your spouse or family.

Appointment reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.

Referrals: We may use and disclose your personal information in order to assist you in seeking referrals to other providers of care, such as consultants or to other health-related services that may be of interest to you.


Right to request restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or payment of your care.  We are not required to agree to your request unless the information is needed to provide you with emergency treatment.  To request restrictions, you must submit your request in writing to the Privacy Officer at this agency. In your request, you must tell us what information you want to limit.  You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations.  For example, you must ask that we only contact you at home or by mail.


You have the right to request a list of the disclosures we made of medical information about you with some exceptions. To request this list, you must submit your request to the Privacy Officer at this agency.  Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years, and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (example: on paper or electronically). The first request within a 12-month period will be free.  For additional copies, we reserve the right to charge a fee.


Right to amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept.  To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this agency. In addition, you must provide a reason that supports your request.  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny the request if the information was not created by us, is not a part of the medical information kept at this agency, is not a part of the medical information which you would be permitted to inspect and copy, or which we deem to be accurate and complete.  If we deny your request for amendment, you have the right to file a statement of disagreement with us.  We may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.  Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized request for information pertaining to the appropriate portion of the record.




Right to inspect and copy: You have the right to Inspect and copy medical information that may be used to make decisions about your care.  Usually this includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal or administrative action or proceeding, and protected health information to which access is prohibited by law.  To inspect and copy information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at this agency.  If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that denial be reviewed.  Another licensed health care professional may be consulted to review your request.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.


Right to a copy of this notice: You have the right to a copy of our current Notice of Privacy Practices at any time by contacting the Privacy Officer at this agency.


Right to request confidential communications: You have the right to specify how we should send communications to you about medical matters, and where you would like those communications sent. To request confidential communications, you must make your request to the Privacy Officer at this agency.  We reserve the right to deny a request.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this agency or with the Secretary of the Department of Health and Human Services, at 200 Independence Avenue, S.W. Room 509F, HHH Building, Washington, D.C. 20201

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