THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: 05/01/2010 Revised Date: 04/01/2019

Definitions and Terms:

PHI – "Protected Health Information"; refers to identifying information in your health records.
Treatment – refers to DocSource's management and coordination of your health care and health care related services, which is included, but not limited to consultation with other health care providers, such as your primary physician or another psychologist.
Payment – refers to reimbursement obtained by DocSource for your health care, which requires disclosure of PHI to a health insurance company to determine coverage eligibility.
Health Care Operations – are activities that relate to the performance and operation of DocSource's practices. Some examples are quality assessment and improvement activities, business audits, administrative services, and case management.
Use – applies only to activities within a particular practice, such as billing, medical records management, and care coordination.
Disclosure – applies to activities that reach beyond a particular practice, such as releasing or providing access to otherwise confidential information about you to other parties (e.g. insurance providers, outside referrals).

I. WE ARE REQUIRED BY LAW TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION (PHI), AND GIVE YOU NOTICE OF OUR LEGAL DUTIES AND PRIVACY PRACTICES:

• We must protect PHI regarding: any PHI we have created or received about your past, present or future health conditions; health care services provided to you; or payment for that care to include protection of substance abuse and HIV/AIDS information.
• We must notify you about HOW we protect PHI about you.
• We must explain HOW, WHEN, and WHY we use and/or disclose your PHI.
• We will provide you a copy of this Notice prior to or when you become a DocSource patient.
• We may only use and/or disclose PHI as we have described in this Notice.
• We reserve the right to change the terms of this Notice and to make new notice provisions for all PHI we maintain. Any changes will apply to all PHI.
• Any updated Notices will be posted on our website: www.docsourceinc.org and by request, will be mailed to you.
• If there is an unauthorized or improper use or disclosure of your protected health information, we are required by law to notify you.

II. WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION FOR THE FOLLOWING PURPOSES:

There are certain times when we may use or disclose your PHI. When we disclose your PHI, we will comply with any and all requirements surrounding the disclosures, including, but not limited to, those found in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as amended by the Health Information and Technology for Economic and Clinical Health Act ("HITECH"), 42 C.F.R. Part 2, and North Carolina General Statutes Chapter 122c.
We are required to disclose health information about you, under certain circumstances:
     1. To you, or your authorized representative, upon request.
     2. To the Secretary of the Department of Health and Human Services, upon request, to determine if we are complying with the Privacy Rule

III. HOW WE MAY USE AND DISCLOSE YOUR PHI:

     a. We may use and disclose PHI about you to provide health care treatment to you, (e.g. in referrals to other DocSource-contracted clinicians).
     b. We may use and disclose PHI about you to obtain payment for services (e.g. to other billing departments, insurance agencies, and collection departments).
     c. We may use and disclose your PHI for health care operations, (e.g. quality improvement assessments, DocSource business improvement evaluations, DocSource business management and administrative activities, grievance policy resolutions, and in compliance with applicable laws and the terms contained herein.
To the extent that any of your PHI includes records covered under 42 C. F. R. Part 2, we will comply with the terms of those regulations regarding disclosure for treatment, payment, and healthcare operations purposes.

IV. WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION UNDER THESE ADDITIONAL CIRCUMSTANCES:

State and Federal laws require or allow that we share your health information with others in specific situations without your consent. Prior to disclosing, we will evaluate each request to ensure that only the minimum necessary information will be disclosed, as well as ensure any required circumstances for disclosure are met.
Abuse/Neglect/Domestic Violence: DocSource, its representatives, and contracted clinicians have a legal and ethical duty to report any such information to the Department of Social Services (DSS) and to release any such information from your records relevant to any investigation conducted by DSS.
Health Oversight: The North Carolina Psychology and Medical Boards have the authority, when necessary; to subpoena records in the event that a DocSource contracted clinician should be the subject of an inquiry. Judicial or Administrative Proceedings (including criminal and civil proceedings): If you are involved in a court proceeding and a request is made for your records or for information about services provided to you through DocSource, this information is considered "privileged" under state law and may not be released without your written consent. However, this privilege does not apply when you are being evaluated for a third party or when the evaluation has been court-ordered. You will be informed in advance if this applies to you.
Serious Threat to One's Health or Safety: When information is obtained by DocSource that indicates a serious and eminent threat to the health and safety of yourself, another person, or the public; this information must be disclosed.
Worker's Compensation: If you file a worker's compensation claim, DocSource is required by law to provide any relevant health information to your employer and to the North Carolina Industrial Commission.

Other instances where we may be required or allowed, limited to the relevant requirements of the law (for instance, as required under State General Statutes, such as NC Chapter 122c):

• DocSource may share confidential information regarding any client with any other facility or healthcare organization when necessary to coordinate appropriate and effective care, treatment or habilitation of the patient. Coordinate shall mean the provision, coordination or management of mental health, developmental disabilities and substance abuse services and other health or related services by one or more facilities and includes the referral of a patient from one facility or provider to another.
• A facility, physician, or other individual responsible for evaluation, management, supervision or treatment of patients examined or committed for outpatient treatment under the provisions of Article 5 of the General Statute (Chapter 122) may request, receive and disclose confidential information to the extent necessary to enable them to fulfill their responsibilities.
• We may exchange confidential information with a physician or other healthcare provider who is providing emergency services to you as a patient. Disclosure of the information is limited to that necessary to meet the emergency as determined by the responsible professional.
• To individuals involved in your care or involved in payment for your care, if you have consented in writing to the release of the information to a specified person. You can object to these releases by telling us that you do not wish any or all individuals involved in your care to receive this information.
• Disclosure of fact of admission or discharge to your next of kin, whenever the responsible professional determines that the disclosure is in the best interest of the patient.
• For public health activities or risks, such as to prevent or control disease, injury or disability, report death, report reactions to medications, or notify of recalls.
• To business associates: DocSource may share your PHI with hired associates of our organization in order for them to do the job we have hired them to do; they are also required to protect your health information and keep it confidential. (e.g., transcriptionists)
• For purpose of activities related to monitoring an FDA- regulated product, to a person subject to the jurisdiction of the FDA.
• For certain law enforcement purposes, such as for the purpose of identifying or locating a suspect or fugitive; or if you are believed to be the victim of a crime.
• To a correctional institution or other law enforcement official having lawful custody of an inmate.
• To a coroner, medical examiner or funeral director, to identify a deceased person or determine a cause of death.
• For organ procurement purposes.
• For research purposes.
• If you are a member of the armed forces, we may release medical information about you as required by military command authorities; we may also use and disclose to components of the Department of Veteran Affairs medical information about you, to determine whether you are eligible for certain benefits.
• For certain Military, National Security and Intelligence activities.

V. CERTAIN USES AND DISCLOSURES WITH YOUR AUTHORIZATION

• We will not use or disclose psychotherapy notes without your written authorization, except as allowed or required by law.
• We will not market or sell your health information without your written authorization, except as allowed or required by law.
• You may revoke a written authorization provided for any of the above purposes at any time, however, the revocation will not apply to any actions we have already taken in reliance on the authorization.

ALL OTHER USES AND DISCLOSURES NOT RECORDED IN THIS NOTICE WILL REQUIRE A WRITTEN AUTHORIZATION FROM YOU OR YOUR PERSONAL REPRESENTATIVE, UNLESS ALLOWED OR REQUIRED BY LAW.

VI. YOUR PATIENT RIGHTS:

All requests to exercise your rights must be made in writing and addressed to the attention of the Privacy Office. Mail: P.O. Box 15390 Wilmington NC 28408 - or – Fax: to 888-746-1787.

Right to Request Restrictions: You have the right to request, in writing, restrictions on certain uses and disclosures of your PHI. DocSource is not required to agree to a requested restriction; even if we agree, your restrictions may not be followed in some situations such as emergencies or when disclosure is required by law. We may accept a restriction request disclosure of information to a health plan if you pay out of pocket in full for service unless it is otherwise required by law.
Right to Receive Confidential Communications by Alternative Means and/or at Alternative Locations: You may request and receive confidential communications of PHI by other means or at other locations. Example: requesting bills be mailed to a location other than your home address.
Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of your PHI for as long as that PHI is maintained in the records. DocSource may deny or limit your access to such records if the information to be release would be injurious to the client's physical or mental well-being, as determined by the physician or, if there is none, the facility director or his designee. You may request that this decision be reviewed by requesting we send such information to a physician or psychologist of the legally responsible person's choice for review, and in this event the information shall be so provided.
Right to Amend: You have the right to request a change, or amendment of PHI for as long as the PHI is maintained in your records. DocSource may deny your request, but will also review the details for the amendment process, upon any patient's request.
Right to an Accounting: You have the right to receive an accounting of disclosures of PHI for which you have provided consent or authorization (as described in Paragraphs II & III, contained herein).
Right to a Paper Copy: You have the right to obtain a paper copy of the notice from DocSource upon request, even if you previously agreed to receive the notice electronically.
Right to Breach Notification: You have the right to receive notification of any breach of your PHI. Right to Treatment: You have the right to treatment, including access to medical care and habilitation, regardless of age or degree of disability.
Right to Consent: You have the right to consent to, or refuse, treatment.

VII. COMPLAINTS

DocSource - A Division of LifeSource, Inc. recognizes the importance of confidentiality, and your right to be fully informed of all regulations regarding protected health information. If you disagree with a decision made by DocSource, regarding your access to records; you may contact the DocSource President at (910) 395-5569. If you file a complaint, we will not retaliate against you for filing a complaint. If you feel that your privacy rights have been violated you may contact the State Secretary of the Department of Health & Human Services. Provision of services will not be affected by the filing of any complaint.

This notice was originally published and becomes effective 5/2010.