YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
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. If you are a current inpatient, you should notify your primary nurse and complete the required form. If you are an outpatient or discharged patient, you should contact the Director of Health Information Services in writing, at the appropriate service location to obtain and complete the required form. If you request a copy of the information, we may 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 the denial be reviewed. Another licensed health care professional chosen by Northside will review your request and the denial. 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 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 by or for Northside. If you are a current inpatient, you should notify your primary nurse and complete the required form. If you are an outpatient or discharged patient, you should contact the Director of Health Information Services in writing, at the appropriate service location to obtain and complete the required form. 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 your request if you ask us to amend information that:
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment and health care operations, as those functions are described above. To request this list or accounting of disclosures, you should contact the Director of Health Information Services in writing, at the appropriate service location to obtain and complete the required form. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. Because any restrictions of your information may hinder the quality of care provided at our facilities, according to the law, we reserve the right to deny such request. In addition, because of the many health care providers participating in the Northside organized health care arrangement, we generally cannot agree to special requests. If we do agree, we will comply with such request unless the information is needed to provide you emergency treatment. You have the right to request that we restrict information from being disclosed to a health plan if the information is related to services for which you have paid for the service in full out of pocket.
To request restrictions, you should contact the Director of Health Information Services in writing, at the appropriate service location to obtain and complete the required form. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. To be binding, any agreement to comply with special restrictions must be in writing signed by the Director of Health Information Services.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Northside Hospital, Attn: Patient Access Department Manager, 1000 Johnson Ferry Road, Atlanta, GA 30342. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to be Notified of a Breach. You have the right to be notified if there is any impermissible use of disclosure of your health information that compromises the privacy or security of your health information.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, www.ngdc.com.
To obtain a paper copy of this notice, you may contact Northside Hospital, Attn: Patient Access Department Manager, 1000 Johnson Ferry Road, Atlanta, GA 30342.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for medical information we already have about you as well as any information we receive in the future. The current
notice will be posted in our facilities and on our website (www.ngdc.com) and you may request a copy of our current notice at any time.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Northside Privacy Officer whose contact information is below or with the Secretary of the Department of Health and Human Services.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose
medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
NORTHSIDE PRIVACY OFFICER
Privacy Officer Contact Phone: 404-845-5534 1000 Johnson Ferry Road Atlanta, GA 30342
Effective Date: April 14, 2003. Revised: August 15, 2003, November 6, 2019, June 14, 2022