DoctorsManagement HIPAA MASTER FORMS
Morganton Internal Medicine, PA
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
The Health Insurance Portability and Accountability Act (HIPAA; “Act”) of 1996, revised in 2013, requires
us as your health care provider to maintain the privacy of your protected health information, to provide
you with notice of our legal duties and privacy practices with respect to protected health information, and
to notify affected individuals following a breach of unsecured protected health information. We are
required to maintain these records of your health care and to maintain confidentiality of these records.
The Act also allows us to use your information for treatment, payment, and certain health operations
unless otherwise prohibited by law and without your authorization.
 Treatment: We may disclose your protected health information to you and to our staff or to other
health care providers in order to get you the care you need. This includes information that may go
to the pharmacy to get your prescription filled, to a diagnostic center to assist with your diagnosis,
or to the hospital should you need to be admitted. If necessary to ensure that you get this care,
we may also discuss the minimum necessary with friends or family members involved in your
care unless you request otherwise.
 Payment: We may send information to you or to your health plan in order to receive payment for
the service or item we delivered. We may discuss the minimum necessary with friends or family
members involved in your payment unless you request otherwise.
 Health operations: We are allowed to use or disclose your protected health information to train
new health care workers, to evaluate the health care delivered, to improve our business
development, or for other internal needs.
 We are required to disclose information as required by law, such as public health regulations,
health care oversight activities, certain law suits and law enforcement.
Certain ways that your protected health information could be used disclosed require an authorization from
you: disclosure of psychotherapy notes, use or disclosure of your information for marketing, disclosures or
uses that constitute a sale of protected health information, and any uses or disclosures not described in
this NPP. We cannot disclose your protected health information to your employer or to your school
without your authorization unless required by law. You will receive a copy of your authorization and may
revoke the authorization in writing. We will honor that revocation beginning the date we receive the
written signed revocation.
You have several rights concerning your protected health information. When you wish to use one of these
rights, please inform our office so that we may give you the correct form for documenting your request.
 You have the right to access your records and/or to receive a copy of your records, with the
exception of psychotherapy notes. Your request must be in writing, and we must verify your
identity before allowing the requested access. We are required to allow the access or provide the
copy within 30 days of your request. We may provide the copy to you or to your designee in an
electronic format acceptable to you or as a hard copy. We may charge you our cost for making
and providing the copy. If your request is denied, you may request a review of this denial by a
licensed health care provider.
 You have the right to request restrictions on how your protected health information is used for
treatment, payment, and health operations. For example, you may request that a certain friend or
family member not have access to this information. We are not required to agree to this request,
but if we agree to your request, we are obligated to fulfill the request, except in an emergency
where this restriction might interfere with your care. We may terminate these restrictions if
necessary to fulfill treatment and payment.
DoctorsManagement HIPAA MASTER FORMS
 We are required to grant your request for restriction if the requested restriction applies only to
information that would be submitted to a health plan for payment for a health care service or item
for which you have paid in full out-of-pocket, and if the restriction is not otherwise forbidden by
law. For example, we are required to submit information to federal health plans and managed
care organizations even if you request a restriction. We must have your restriction documented
prior to initiating the service. Some exceptions may apply, so ask for a form to request the
restriction and to get additional information. We are not required to inform other covered entities
of this request, but we are not allowed to use or disclose information that has been restricted to
business associates that may disclose the information to the health plan.
 You have the right to request confidential communications. For example, you may prefer that we
call your cell phone number rather than your home phone. These requests must be in writing,
may be revoked in writing, and must give us an effective means of communication for us to
comply. If the alternate means of communications incurs additional cost, that cost will be passed
on to you.
 Your medical records are legal documents that provide crucial information regarding your care.
You have the right to request an amendment to your medical records, but you must make this
request in writing and understand that we are not required to grant this request.
 You have the right to an accounting of disclosures. This will tell you how we have used or
disclosed your protected health information. We are required to inform you of a breach that may
have affected your protected health information.
 You have the right to receive a copy of this notice, either electronic or paper or both.
 You have the right to opt out of fund raising communications.
If you have any questions about our privacy practices, please contact our Privacy Officer at the number
below.
You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or
retaliate in any way for this action. To file a complaint, please contact the applicable party:
Privacy Officer: Dedra Pasco
Phone number: __828-433-0225_____________________
Fax number: ___828-437-0227______________________
Office for Civil Rights
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
We are required to abide by the policies stated in this Notice of Privacy Practices, which became
effective on (date)_08/23/2022_________.