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.
EFFECTIVE: APRIL 14, 2003
LAST REVISED: OCTOBER 2018
ECU Health includes the following entities:
- ECU Health Beaufort Hospital
- Ahoskie Imaging, LLC
- Duplin Healthcare Services, LLC
- East Carolina Endoscopy Center
- Outer Banks Hospital
- Outer Banks Professional Services, LLC
- Radiation Services of North Carolina, LLC
- ECU Health Bertie Hospital
- ECU Health Cancer Care at the Eddie and Jo Allison Smith Tower
- ECU Health Chowan Hospital
- ECU Health Duplin Hospital
- ECU Health Edgecombe Hospital
- ECU Health Endoscopy Center-Kinston
- ECU Health Endoscopy-Tarboro
- ECU Health Home Health & Hospice
- ECU Health Medical Center
- ECU Health Physicians
- ECU Health Roanoke-Chowan Hospital
- ECU Health SurgiCenter
Our privacy practices
As a major resource for health services and education, ECU Health strives to support local medical communities and to work with providers throughout the region to deliver quality care. Your privacy is important to us, and it is our policy to respect your privacy when you are our patient.
Summary of your rights to privacy
ECU Health has a legal duty to protect health information about you. ECU Health may use and disclose protected health information (PHI) about you without your authorization in the following circumstances:
- To provide healthcare treatment to you.
- To obtain payment for services.
- For healthcare operations.
- Under other certain circumstances.
- You can object to certain uses and disclosures.
- We may contact you to provide appointment reminders.
- We may contact you with information about treatment,
services, products or healthcare providers.
- We may contact you for fundraising activities.
You have several rights regarding PHI about you:
- You have the right to make a formal complaint/grievance
about our privacy practices.
- You have the right to request restrictions on uses and
disclosures of your information.
- You have the right to request different ways to communicate
- You have the right to a copy of your information.
- You have the right to request an amendment of your information.
- You have the right to a listing of disclosures we have made.
- You have the right to a complete copy of our Notice of Privacy Practices.
Our duty to protect your information
We are required to do the following:
We are required to protect the privacy of health information about you that can identify you (which we call protected health information, or PHI for short). We must give you notice of our legal duties and privacy practices concerning PHI:
- We must protect PHI that we have created or received about
your past, present, or future health condition, healthcare we
provide to you, or payment for your healthcare.
- We must notify you about how we protect PHI about you.
- We must explain how, when and why we use and/or disclose
PHI about you.
- We may only use and/or disclose PHI about you as we have
described in this Notice.
- We must provide you with sufficient notice if we acquire, access, use
or disclose your PHI in a manner that is not permitted under this
Notice and compromises the security or privacy of the PHI.
- We are required to follow the procedures in this Notice.
We reserve the right to change the terms of this Notice and to make
new notice provisions effective for all PHI that we maintain by first:
- Posting the revised Notice in our facility.
- Making copies of the revised Notice available upon request (either at our facility or through the appropriate Privacy Officer listed on the back cover of this Notice), and Posting the revised Notice on our website.
How we may use and disclose your information
We may use and disclose PHI about you without your
authorization in the following circumstances:
General: We may use and disclose PHI about you to provide, coordinate
or manage your health care and related services. This may include
communicating with other healthcare providers about your treatment and
coordinating and managing your healthcare with others. For example, we
may use and disclose PHI about you when you need a prescription, lab
work, an x-ray or other healthcare services. In addition, we may use and
disclose PHI about you when referring you to another healthcare provider.
Example: A doctor treating you for a broken leg may need to know if
you have diabetes because diabetes may slow the healing process. In
addition, the doctor may need to tell the dietitian if you have diabetes so
that we can arrange for appropriate meals. Departments of the hospital
may also need to share your PHI about you in order to coordinate different
services you may need, such as prescriptions, lab work and x-ray’s. We may
also disclose PHI about you to people outside the hospital who may be
involved in your medical care after you leave the hospital, such as home
health providers or others who may provide services that are part of your
Example: Your doctor may share medical information about you with
another healthcare provider. For example, if you are referred to another
doctor, that doctor will need to know if you are allergic to any medications.
Similarly, your doctor may share PHI about you with a pharmacy when
calling in a prescription.
Health Information Exchanges
We may use and disclose PHI about you for treatment purposes.
This facility may participate in electronic health information exchanges
that allow patient information to be shared with providers who are
involved in your treatment and care. These exchanges provide a fast,
secure, and reliable way to deliver health information to providers. The
health information is shared in accordance with this Notice of Privacy
Practices and federal and state law. Patients have the right to opt out of the
electronic health information exchange by completing the Opt Out Form
at https://www.ecuhealth.org/patients-and-families/preparing-for-your-stay/patient-rights-responsibilities/ or notifying registration staff. If you choose to
opt out, providers must request and receive your information using other
methods, such as, fax or mail.
If you have previously opted out of electronic health information
exchanges and would like to opt in, you may obtain a form from this
facility from the ECU Health website or from patient registration staff.
Complete the form and return to the address listed on the form or to the
We may participate in NC HealthConnex (the “NC Exchange”) through
the North Carolina Health Information Exchange Authority, or similar
initiatives. If we participate in the NC Exchange, we will share your PHI with
the NC Exchange and may use the NC Exchange to access your PHI. Access
to your PHI will allow treating providers to make more informed decisions
about your care. Opting out may prevent providers from obtaining PHI
beneficial to your treatment. If you do not want your PHI accessible to NC
Exchange participants, you must opt out by submitting a form directly to
the NC Exchange. The opt out form may be downloaded directly from the
NC Health Information Exchange Authority website (https://hiea.nc.gov/
patients/your-choices). You can rescind your decision to opt out using that
same form. Information explaining the benefits of the NC Exchange and
instructions on how to opt-out or rescind your opt out are available on
the NC Exchange website. Even if you opt out of the NC Exchange, we may
use or disclose your PHI available from the NC Exchange for public health
or research purposes authorized by law. Your opt out will also not affect
our obligation to disclose your PHI to the NC Exchange when you receive
hospital services that are paid for by Medicaid or other North Carolina
State funding sources.
We may use and disclose PHI about you to obtain payment
Generally, we may use and give your medical information to others to
bill and collect payment for the treatment and services provided to you.
Before you receive scheduled services, we may share information about
these services with your health plan(s). Sharing information allows us to
ask for coverage under your plan or policy and for approval of payment
before we provide the services. We may also share portions of your medical
information with the following:
- Billing departments.
- Collection departments or agencies.
- Insurance companies, health plans and their agents which provide
- Hospital departments that review the quality and cost of the care
- Consumer reporting agencies (e.g., credit bureaus).
Example: Let’s say you have a broken leg. We may need to give your health
plan(s) information about your condition, supplies used (such as plaster for
your cast or crutches), and services you received (such as x-rays or surgery).
The information is given to our billing department and your health plan
so we can be paid or you can be reimbursed. We may also send the same
information to our hospital department which reviews our care of your
illness or injury.
We may use and disclose PHI about you for healthcare operations.
We may use and disclose PHI about you when we perform business
activities, that we call healthcare operations. These healthcare operations
allow us to improve the quality of care we provide and reduce healthcare
costs. We may use or reveal PHI about you to carry out certain business
actions separately or as part of our involvement in an Organized Health
Care Arrangement (OHCA) with ECU Health Care Components or as part
of an OHCA with the credentialed and privileged members of our medical
staff. Examples of the way we may use or disclose PHI about you for
healthcare operations include:
- Reviewing and improving the quality, efficiency and cost of
care we provide to you and other patients. For example, we
may use PHI about you to develop ways to help our healthcare
providers and staff decide what medical treatment should be
provided to others.
- Improving healthcare and lowering costs for groups of people
who have similar health problems, and managing and coordinating
the care for these groups. We may use PHI to identify people with
similar health problems and to give them information about
treatment alternatives, classes or new procedures.
- Reviewing and evaluating the skills, qualifications and performance
of healthcare providers taking care of you.
For example, you may be contacted by a survey vendor to ask about
your experience, at which time you may decline to answer questions.
If you wish not to be contacted by the survey vendor you may opt
out by notifying our hospital registration staff.
- Providing training programs for students, trainees, healthcare
providers or non-health care professionals (for example, billing
clerks or assistants, etc.) to help them practice or improve their skills.
- Cooperating with outside organizations that assess the quality
of the care we and others provide. These organizations might
include government agencies or accrediting bodies such as
The Joint Commission.
- Cooperating with outside organizations that evaluate, certify or
license healthcare providers, staff or facilities in a particular field or
specialty. For example, we may use or disclose PHI so that one of our
nurses may become certified in a specific field of nursing, such as
- Assisting various people who review our activities. For example, PHI
about you may be seen by doctors reviewing the services provided
to you, or by accountants, lawyers and others who assist us in
complying with applicable laws.
- Planning for our organization’s future operations and fundraising
for the benefit of our organization.
- Conducting business management and general administrative
activities related to our organization and the services it provides,
including providing information.
- Resolving grievances within our organization.
- Reviewing activities and using or disclosing PHI in the event that
we sell our business, property or give control of our business or
property to someone else.
- Complying with this Notice and with applicable laws.
We may use and/or disclose PHI about you in certain circumstances
that do not require your consent or agreement as described below.
- Use and/or disclosure required by law. For example, a
disclosure that is required by federal, state or local law or
other judicial or administrative proceeding.
- Use and/or disclosure necessary for public health activities.
For example, we may disclose PHI about you if you have
been exposed to a communicable disease or may otherwise
be at risk of contracting or spreading a disease or condition.
- Disclosure relating to victims of abuse or neglect.
- Use and disclosure for health oversight activities. For example,
we may disclose PHI about you to a state or federal health
oversight agency which is authorized by law to oversee our
- Disclosure for judicial and administrative proceedings. For
example, we may disclose PHI about you in response to an
order of a court or administrative tribunal.
- Disclosure for law enforcement purposes. For example,
we may disclose PHI about you in order to comply with laws
that require the reporting of certain types of wounds or other
- Use and/or disclosure relating to decedents. For example, we
may disclose PHI about you to a coroner or medical examiner
for the purposes of identifying you should you die.
- Use and/or disclosure relating to cadaveric organ, eye or
- Use and/or disclosure relating to medical research. Under
certain circumstances, we may disclose PHI about you for
- Use and/or disclosure to avert a serious threat to health or
safety. For example, we may disclose PHI about you to prevent
or lessen a serious and eminent threat to the health or safety
of a person or the public.
- Use and/or disclosure relating to specialized government
functions. For example, we may disclose PHI about you if
it relates to military activities, national security and intelligence
activities, or protective services for the President.
- Use and/or disclosure relating to correctional institutions
and in other law enforcement custodial situations. For
example, in certain circumstances, we may disclose PHI about
you to a correctional institution having lawful custody of you.
Unless you instruct us otherwise, we may disclose your
information as described below.
- To maintain our facility directory. If a person asks for you by
name, we will only disclose your name, general condition, and
location in our facility. We also may share your religious
affiliation with clergy.
- We may share with a family member, relative, friend or other
person identified by you, PHI about you directly related to
that person’s involvement in your care or payment for your
care. We may share with a family member, personal
representative or other person responsible for your care, PHI
about you necessary to notify such individuals of your location,
general condition or death.
- We may share with a public or private agency (for example,
American Red Cross) PHI about you for disaster relief
purposes. Even if you object, we may still share the PHI about
you, if necessary for emergency circumstances.
- If you would like to object to our use or disclosure of PHI about you
in the above circumstances, please call the appropriate Privacy
Officer listed on the back cover of this Notice.
We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to
you about an appointment you have for treatment or medical care.
We may contact you with information about treatment, services,
products, and healthcare providers.
We may use and/or disclose PHI to manage or coordinate your healthcare.
This may include telling you about treatments, services, products, and
other healthcare providers. We may also use and/or disclose PHI about you
to give you gifts of small value.
Example: If you are diagnosed with diabetes, we may tell you about
nutritional and other counseling services that may be of interest to you.
We may contact you for fundraising activities.
We may use limited information to contact you in the future to raise
money for an ECU Health facility. We may also provide this information
to our institutionally related foundation for the same purpose. The money
raised will be used to expand and improve the services and programs we
provide the community. You may opt out of receiving future fundraising
communications at any time.
Other uses and disclosures requiring your written authorization
We will ask for your written authorization before using or disclosing PHI for
purposes not described in this Notice, including most marketing purposes
or we seek to sell your information. If you sign a written authorization
allowing us to disclose PHI about you in a specific situation, you can later
cancel your authorization in writing. If you cancel your authorization
in writing, we will not disclose PHI about you after we receive your
cancellation, except for disclosures that were being processed before we
received your cancellation or are otherwise permitted under this Notice.
Your rights under this notice
Right to notification about a Breach.
You have the right to be notified in the event we inappropriately use
access or disclose your PHI.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this Notice upon request, even if you
have agreed to receive the Notice electronically.
You have the right to request different ways to communicate
We normally contact you by telephone or mail at your home address. You
may request that we contact you by alternative means or at alternative
locations. We will accommodate reasonable requests, but when
appropriate, may condition that accommodation on your providing us
with information regarding how payment, if any, will be handled. You may
request alternative communications by notifying the person registering
you or your healthcare provider.
All of the following rights require you to submit a written request form to us. If
you would like to exercise any of these rights please contact the ECU Health
Privacy Officer listed on the last page of this Notice.
You have the right to request restrictions on uses and disclosures
of PHI about you.
You have the right to request additional restrictions on the use or
disclosure of information for treatment, payment or healthcare operations.
We are not required to agree to your requested restrictions, except in
limited situations in which you or someone on your behalf pays for an
item or service, and you request that information concerning such item
or service not be disclosed to a health insurer. However, your request may
still not be followed in certain situations such as emergency treatment,
disclosures to the Secretary of the Department of Health and Human
Services, and uses and disclosures described in the previous sections of
You have the right to see and receive a copy of PHI about you.
You have the right to request to see and receive a copy of PHI about you
contained in clinical, billing and other records used to make decisions
about you. We may charge you related fees. Instead of providing a full
copy of the PHI about you, we may give you a summary or explanation
of the PHI about you, if you agree in advance to the form and cost of the
summary or explanation. In certain situations, we are not required to
comply with your request. Under these circumstances, we will respond to
you in writing, stating why we will not grant your request and describing
any rights you may have to request a review of our denial. You may request
to see and receive a copy of PHI about you by contacting your provider’s
medical records department.
You have the right to request an amendment of PHI about you.
You have the right to request that we make amendments to clinical,
billing and other records used to make decisions about you. Your request
must be in writing and must explain your reason(s) for the amendment.
We may deny your request if: 1) the information was not created by us
(unless you prove the creator of the information is no longer available
to amend the record); 2) the information is not part of the records used
to make decisions about you; 3) we believe the information is correct
and complete; or 4) you would not have the right to see and copy the
record as described in the previous paragraph. We will tell you in writing
the reasons for the denial and describe your rights to give us a written
statement disagreeing with the denial. If we accept your request to amend
the information, we will make reasonable efforts to inform others of the
amendment, including persons you name who have received PHI about
you and who need the amendment. You may request an amendment of
PHI about you by contacting your provider’s medical records department.
You have the right to a listing of disclosures we have made.
You have the right to receive a written list of certain disclosures of PHI
about you. You may ask for disclosures made up to six years before your
request date. We are not required to include disclosures:
- For your treatment,
- For billing and collection of payment for your treatment.
- For our healthcare operations,
- Requested by you, that you authorized or that are made to
individuals involved in your care, and
Allowed by law.
We reserve the right to change the terms of this Notice and make the new
provisions effective for all PHI that it maintains. If we revise this Notice, a
copy will be made available to you upon request.
You may file a complaint about our privacy practices.
If you think your privacy rights have been violated by us, or you want to
complain to us about our privacy practices, you can contact one of the
privacy officers on the back cover of this Notice. All complaints will be
investigated to help resolve any issues you may have. You may also send a written complaint to the United States Secretary of the Department of
Health and Human Services. If you file a complaint, we will not take any
action against you or change our treatment of you in any way.
In some cases, North Carolina or Federal law may provide additional
protection for your PHI. In the following situations, we will follow the
practices specified in this section before using or disclosing the PHI
affected in accordance with the remainder of this Notice.
Treatment for drug dependence
If you request treatment and rehabilitation for drug dependence, we will
not disclose your name to any police officer or other law-enforcement
officer unless you consent to our sharing of it.
If you suffer from a communicable disease (for example, tuberculosis,
syphilis or HIV/AIDS), information about your disease will be treated as
confidential. We will only release such information under the following
circumstances: 1) for statistical purposes in a way that does not identify
you; 2) with your written consent or the written consent of your guardian;
3) to other healthcare personnel providing you with treatment; 4) to
protect the public health and as provided by regulation; 5) to report as
required by law; 6) pursuant to a subpoena or court order; 7) as otherwise
specifically authorized or required by law.
Mental health services
One or more of the facilities covered by this Notice may be required to
keep confidential information relating to mental health services, including
treatment for mental illness, developmental disability or substance abuse.
Such information will not be disclosed without your written consent,
except in certain circumstances, potentially including the following:
- To individuals within our facility involved in your treatment or
- To other facilities when necessary to coordinate appropriate
and effective care, treatment or rehabilitation,
- To your next of kin upon your request if the next of kin plays a
legitimate role in your treatment,
- When in our opinion there is an imminent danger to the health
or safety of another individual,
- To a provider of support services,
- To a state or governmental agency when we believe you may
be eligible for financial benefits through such agency,
- To researchers if there is a justifiable documented need for the
- To report suspected neglect or abuse as required by law,
- To make other reports to the state as required by law,
- Upon court order,
- To a prosecuting attorney and to your attorney in a case where
you are a criminal defendant and a mental examination has
been ordered by the court,
- To the attorney general’s office when the information is
necessary for performance of the statutory responsibilities of
the attorney general,
- To our attorney if such information is relevant to litigation
involving our facility, and
- To an attorney upon your request.
Furthermore, if we determine that the disclosure is in your best interest we
may: (i) disclose information about your admission or discharge to your
next of kin, and (ii) disclose confidential information for purposes of filing
a petition for involuntary commitment or a petition for adjudication of
To the extent that any PHI can identify you as a substance abuse patient,
such information may be entitled to stricter protection, and we will comply
with any applicable law restricting the disclosure of such information.
Federally assisted alcohol and drug treatment programs
If you are receiving treatment in a federally assisted alcohol and drug
treatment program, your health information may be disclosed without
your written consent only as follows:
- Within the program for activities related to the provision of
substance abuse diagnosis, treatment, or referral for treatment.
- To respond to a medical emergency.
- When required by a court order issued in accordance with
- To communicate with law enforcement personnel about a
crime or threatened crime on the premises of a program or
against program personnel.
- To qualified personnel for a research, audit, or evaluation activity.
- To comply with state law mandating the reporting of child abuse
Inspections and surveys
One or more of our facilities and services are subject to inspection by State
representatives who may as a part of this process review patient health
information. If you receive services from our hospice, home health agency,
ambulatory surgery center or outpatient cardiac rehabilitation program,
we will provide you with written notice and the opportunity to object to
their review prior to the release of your information.
If you are under the age of 18, are not married and have not been
emancipated by an order of the court, you may consent to treatment for
the following services without the consent of your parents and therefore
may exercise the rights and authority set forth in this Notice: treatment for
venereal disease, pregnancy, drug and/ or alcohol abuse, and emotional
disturbance. Exceptions to state law in this regard include instances in
which your physician determines that this information should be shared
with your parents or guardian because of a serious threat to your life or
health, or in instances in which your parents or guardian contact the
physician directly concerning the treatment of one of these conditions.
Effective Date of this Notice
The effective date of this Notice is April 14, 2003.
HOW TO CONTACT US
ECU Health includes the following entities, listed with their main
numbers and Privacy Officer contact numbers.
ECU Health Privacy Officer…………………………….. 252-847-6545
Ahoskie Imaging, LLC ………………………………………………….. 252-209-8483
Duplin Healthcare Services, LLC……………………………….. 910-285-1799
East Carolina Endoscopy Center……………………………….. 252-847-4570
Outer Banks Hospital…………………………………………………… 252-449-4542
Outer Banks Professional Services, LLC………………….. 252-847-2181
Radiation Services of North Carolina, LLC……………… 252-209-8483
ECU Health Beaufort Hospital ……………………………………………. 252-975-4100
ECU Health Bertie Hospital…………………………………………………. 252-794-6600
ECU Health Cancer Center at the
Eddie and Jo Allison Smith Tower…………………………….. 252-816-2273
ECU Health Chowan Hospital……………………………………………… 252-482-8451
ECU Health Duplin Hospital………………………………………………… 910-296-0941
ECU Health Edgecombe Hospital………………………………………. 252-641-7700
ECU Health Endoscopy Center-Kinston …………………………… 252-233-3231
ECU Health Endoscopy Center-Tarboro …………………………… 252-563-1036
ECU Health Home Health and Hospice…………………………….. 252-847-6225
ECU Health Medical Center…………………………………………………. 252-847-4100
ECU Health Physicians………………………………………………….. 252-847-6156
Privacy Officer……………………………………………………………. 252-847-9559
ECU Health Roanoke-Chowan Hospital…………………………… 252-209-3000
Privacy Officer……………………………………………………………. 252-209-3270
ECU Health SurgiCenter……………………………………………………….. 252-847-7700
Privacy Officer……………………………………………………………. 252-847-7723