OUR COMMITMENT
As an individual who receives health care services, we understand that you may be concerned about how your health information may be used, disclosed, created, maintained, or otherwise handled. As your health care provided, we are committed to maintaining the privacy and confidentiality of your individual health information. This notice is provided to our patients in order to comply with the HIPPA Privacy Rules pertaining to your individually identifies health information, referred to a “Protected Health Information” (PHI).

CHANGES TO THIS NOTICE
We may change our policies at any time. Changes will apply to health information that we already hold, as well as new health information that we obtain after the change. After a significant change to our policy, we will change our public notices to reflect this change and post them in the waiting area, the exam rooms, and the check out area. You may receive a current notice at any time. The effective date will be listed under the title. You will be offered a copy of the current notices each time you come in for treatment at our facility. You will also be asked to acknowledge in writing your receipt of this notice.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
We may use and disclose your treatment (such as sending information to another treating physician or pharmacy as part of your ongoing treatment); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our health care operations (such as comparing patient information to improve treatment methods).

In certain instances, we may use of disclose your health information without your prior authorization, such as for public health purposes, FDA regulation of products, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements and organ donation, worker’s compensation purposes, and emergencies. We also disclose medical information when required by law such as to assist law enforcement in cases legally required and to comply with orders issues by judicial or administrative proceedings. Even in these instances, we intend to ensure that PHI is not used or disclosed unless all applicable prerequisites and preconditions set forth in the HIPPA Privacy Rules are met. In addition, where patient PHI is disclosed without the patient’s verbal or written pre-approval, we shall endeavor to account for the disclosures of such PHI to the extent required by the HIPPA Privacy Rules.

We may disclose medical information to a friend or a family who is involved in your medical care or to disaster relief authorities so that your family can be notified of your location and condition.

Unless you choose to decline the information, we may contact you to tell you about healthcare alternatives of for the purposes of development, marketing, or fundraising activities. In addition, we may use of disclose your PHI for patient scheduling purposes, and we may also use or disclose incidentally to other permitted uses or disclosures.

RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the right to request additional restrictions on the use or disclosure of your Protected Health information; that is, restrictions beyond those otherwise required by the HIPPA Privacy Rules. This includes the right to request that your Protected Health Information be communicated to you in a confidential manner. All requests must be in writing. Although we will act in good faith in addressing any such requests, we are not obligated to agree to additional restrictions.

You have a right to request review and obtain copies of your Protected Health Information. Under South Carolina law, a written consent, signed by you or your legal representative is required before we may release copies of your medical record. In addition, if you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.

You have the right to request an amendment to your Protected Health Information. Your request must be in writing and give the reason for the requested amendment or correction. We can deny your request to amend a record if we did not created the information; if it is not a part of the medical information that we maintain; or if we determine that the record is accurate. You may appeal, in writing, our decision not to amend the record.

You have a right to request an accounting or list of disclosures of your Protected Health Information. We are not required to account for the following disclosures: for treatment purposes; for disclosures to the patient of the patient’s legal representative; for the purpose of notifying family members and loved ones of the patient’s condition of location; for national security or intelligence purposes; for certain correctional institution and law enforcement purposes; or those disclosures occurring before the HIPPA Privacy Rules Compliance Date of April 14, 2003. The first disclosure list request in a 12-month period is free; other requests will be charged a fee as allowed by South Carolina law.

You have a right to obtain a paper copy of this Privacy Notice. You may request a copy at any time by contacting the office at the address below. We may also provide copies of this Privacy Notice via E-mail and/or website, as applicable, and as permitted by the HIPPA Privacy Rules.

HIPPA COMPLIANT AUTHORIZATIONS
A HIPPA complaint Authorization may be required under certain circumstances. For example, we may ask you to execute an Authorization when an employer asks us to disclosure PHI about a patient-employee; or when a family member requests to see your PHI; or for public relations/media purposes; of for the use of disclosure of patient psychotherapy notes. Should you ever be asked to execute an Authorization, it is important that you are aware of the following:

In most cases, we may not condition health care services or treatment, payment, enrollment, or eligibility on your providing an Authorization.

In some cases, we may condition our services upon receipt for you of an Authorization. For example, we may condition the provision of health care services when the health care services are solely for the purpose of creating PHI for the benefit of a third party.
You always have the right to request, in writing, that an Authorization executed by you be revoked. When you revoke a prior Authorization, the revocation does not apply to actions taken in reasonable reliance on your prior Authorization.

Whenever you execute an Authorization that refers you to our Privacy Notice for more information, the applicable Privacy Notice is in the one in effect at the time of your reference. For that reason, should we ever revise our Privacy Notice after you have executed and Authorization, the revised Notice will apply whether or not the revised Notice was in effect at the time that you executed the Authorization.

HIPPA Privacy Rules do not require us to account for disclosures of your PHI that are made in accordance with an Authorization that you executed.

COMPLAINTS
You have a right to complain about you’re your Protected Health Information is handled. If you ever have questions, concerns, issues and/or complaints regarding your privacy or confidentiality rights, you may contact our Privacy Responsibility Officer at 864-295-3600, extension 117 or by mail to the address listed below. In addition, should you find that we have not been attentive to your privacy, confidentiality or other rights under the HIPPA Privacy Rules, you may contact the U.S. Department of Health and Human Services Office of Civil Rights at 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C., 20201; Voice Hotline Number: (800) 368-1019; Internet Address: www.hhs.gov/ocr:
E-mail Address: ocrmail@hhs.gov. Under no circumstances will you be penalized or retaliated against for filing a complaint.

WRITTEN ACKNOWLEDGEMENT OF PATIENT OR PERSONAL REPRESENTATIVE OF PATIENT:
____________________________                ____________________
Signature of Patient/Personal Representative Social Security Number

Date _______________________