Effective Date July 1, 2011

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

We are required by law to maintain the privacy of your health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; and to abide by the terms of the Notice that are currently in effect. This Notice applies to our use and disclosure of your health information for purposes of enrollment, eligibility and payment under the PACE of Guilford and Rockingham Counties program as well as our use and disclosure of your health information for purposes of providing you with treatment under the PACE of Guilford and Rockingham Counties program.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following lists various ways in which we may use or disclose your protected health information (“PHI”) for purposes of treatment, payment and health care operations.

For Treatment. We will use and disclose your PHI in providing you with treatment and services and coordinating your care and may disclose your PHI to other providers involved in your care. Your PHI may be used by doctors involved in your care and by nurses and home health aides as well as by physical therapists, social workers, personal care attendants or other persons involved in your care. For example, members of the multidisciplinary team (which includes your primary care physician, a registered nurse, a social worker, physical and occupational therapists, and other care givers) will discuss your plan of care and contact any specialists regarding care provided to you.

For Payment. We may use and disclose your PHI for billing and payment purposes. We may disclose your PHI to your personal representative, or to an insurance or managed care company, Medicare, Medicaid or the state agency charged with administering PACE of Guilford and Rockingham Counties programs. For example, we may disclose PHI to Medicare or the state administering agency in order to determine your continued eligibility for PACE of Guilford and Rockingham Counties services. We will also require you to sign a release permitting the disclosure of personal information to Medicare, Medicaid, and the state administering agency for these purposes as a condition of your enrollment agreement.

For Health Care Operations. We may use and disclose your PHI as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor quality of care. For example, we will use data about your treatment in order to conduct quality assessment activities. We may disclose your PHI to another entity with which you have or had a relationship if that entity requests your PHI for certain of its health care operations or health care fraud and abuse detection or compliance activities.

II. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following lists various ways in which we may use or disclose your PHI.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose PHI about you to a family member, close personal friend or other person you identify, including clergy, who is involved in your care.

Emergencies. We may use and disclose your PHI as necessary in emergency treatment situations.

As Required By Law. We may use and disclose your PHI when required by law to do so.

Business Associates. Our business associates are individuals and organizations that carry out functions or activities on our behalf that involve protected health information. We may disclose your PHI to a business associate who needs the information to perform services for PACE of Guilford and Rockingham Counties. Our business associates are committed to preserving the confidentiality of this information.

Public Health Activities. We may disclose your PHI for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting elderly abuse or neglect; or reporting deaths.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your PHI to notify a government authority, if authorized by law or if you agree to the report.

Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system. As a condition of enrollment, we will require you to sign a release permitting the disclosure of personal information to Medicare, Medicaid, and the state administering agency for these purposes.

To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use and disclose your PHI, limiting disclosures to someone able to help lessen or prevent the threatened harm.

Judicial and Administrative Proceedings. We may disclose your PHI in response to a court or administrative order. We also may disclose your PHI in response to a subpoena, discovery request, or other lawful process, provided certain conditions are met. These conditions include making efforts to contact you about the request or obtaining an order or agreement protecting the PHI.

Law Enforcement. We may disclose your PHI for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to respond to certain requests for information concerning crimes.

Research. We may use and disclose your PHI for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your PHI to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

Disaster Relief. We may disclose your PHI to a disaster relief organization.

Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your PHI as required by military command authorities. We may disclose your PHI for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.

Workers’ Compensation. We may use and disclose your PHI to comply with laws relating to workers’ compensation or similar programs.

Inmates/Law Enforcement Custody. If you are under the custody of a law enforcement official or a correctional institution, we may disclose your PHI to the institution or official for certain purposes including the health and safety of you and others.

Fundraising Activities. We may use and disclose certain limited contact information for fundraising purposes and may provide contact information to a foundation affiliated with our PACE of Guilford and Rockingham Counties, provided that any fundraising communications explain clearly and conspicuously your right to opt out of future fundraising communications. We are required to honor your request to opt out.

Appointment Reminders. We may use and disclose health information to remind you about appointments.

Treatment Alternatives and Health-Related Benefits and Services. Subject to certain limitations, we may use or disclose your PHI to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

 III. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your PHI only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your PHI for the purposes covered by that Authorization, except where we have already relied on the Authorization.

IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your PHI. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to PACE of Guilford and Rockingham Counties. At your request, PACE of Guilford and Rockingham Counties will supply you with the appropriate form to complete.

Request Restrictions. You have the right to request restrictions on our use and disclosure of your PHI for treatment, payment, or health care operations. This includes the right to submit a written consent limiting the degree of information disclosed and the persons to whom information is disclosed. You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.

We are not required to agree to your requested restriction on how we use your health information within PACE of Guilford and Rockingham Counties. We will limit disclosures outside PACE of Guilford and Rockingham Counties (except for disclosures to the Centers for Medicare and Medicaid Services (“CMS”) and the state administering agency) in accordance with your written consent. We will grant requests to restrict use of protected health information within PACE of Guilford and Rockingham Counties if they are reasonable and can be accommodated. If we do agree to accept your requested restriction, we willcomply with your request except as needed to provide you emergency treatment or in accordance with applicable law.

Access to Personal Health Information. You have the right to inspect and obtain a copy of your clinical and billing records and other written information that may be used to make decisions about your care, subject to some exceptions. Your request must be made in writing. In most cases we may charge a reasonable fee for our costs in copying and mailing your requested information, consistent with applicable law.

To the extent we maintain an electronic health record with respect to your PHI, you also have the right to receive an electronic copy of such information, and to direct us to transmit an electronic copy directly to a third-party designated by you. We may charge a fee, consistent with applicable law, for our labor costs in responding to your request.

Request Amendment. You have the right to request amendment of your PHI maintained by PACE of Guilford and Rockingham Counties for as long as the information is kept by or for PACE of Guilford and Rockingham Counties. Your request must be made in writing and must state the reason for the requested amendment.

We may deny your request for amendment if the information (a) was not created by PACE of Guilford and Rockingham Counties, unless the originator of the information is no longer available to act on your request; (b) is not part of the PHI maintained by or for PACE of Guilford and Rockingham Counties; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by PACE of Guilford and Rockingham Counties.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and an explanation of your right to submit a written statement disagreeing with the denial.

Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your PHI. This is a listing of disclosures made by PACE of Guilford and Rockingham Counties or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosures made pursuant to your Authorization, and certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after May 1, 2011 that is within six years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.

Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. In addition, you may obtain a copy of this Notice at our website, www.pacetriad.org.

Receive an Electronic Copy of Your Electronic Health Record. To the extent we maintain an electronic health record with respect to your PHI, you also have the right to receive an electronic copy of such information, and to direct us to transmit an electronic copy directly to a third-party designated by you. We may charge a fee, consistent with applicable law, for our labor costs in responding to your request.

Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.

V. BEHAVIORAL HEALTH CARE

Regardless of the other parts of this Notice, any information relating to alcohol and drug treatment or other behavioral health care treatment, including psychotherapy notes, will not be disclosed outside of PACE of Guilford and Rockingham Counties, Inc. except as authorized by you in writing, pursuant to a court order, or as required by law. Private notes that our licensed and certified therapist or social workers have made during a session with you that are kept in the professionals personal files, and specifically designated as psychotherapy notes will not be disclosed to personnel working within PACE of Guilford and Rockingham Counties, other than to the person who wrote the notes, except for training purposes or to defend a legal action brought against PACE of Guilford and Rockingham Counties, or unless you have properly authorized such disclosure in writing.

 VI. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Ursula Robinson, Program Director at (336) 550-4040.

If you believe that your privacy rights have been violated, you may file a complaint in writing with the PACE Program or with the Office for Civil Rights in the U.S. Department of Health and Human Services (“OCR”). We will not retaliate against you for filing a complaint.

To file a complaint with PACE of Guilford and Rockingham Counties, contact Ursula Robinson, Program Director at (336) 550-4040.

To file a complaint with OCR, send your written complaint to OCR by mail at Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201 or by email to OCRComplaint@hhs.gov.

VII. CHANGES TO THIS NOTICE

We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all PHI already received and maintained by PACE of Guilford and Rockingham Counties as well as for all PHI we receive in the future. We will provide a copy of the revised Notice upon request.