123 456 789
info@example.com
Goldsmith Hall
New York, NY 90210
07:30 - 19:00
Monday to Friday
(Effective Date: Sept. 1, 2003, last updated April 2026)
(This will serve as acknowledgement of the receipt of Peak Resources’ and our Pharmacy Provider’s 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.
If you have any questions about this Notice of Privacy Practices (this “Notice”), please contact the Corporate Privacy Officer at 919-290-2722.
WHO WILL FOLLOW THIS NOTICE?
This notice describes Peak Resources, Inc.’s (hereafter referred to as “Nursing Home”) practices at all its locations and that of:
THE MEDICAL INFORMATION TO WHICH NOTICE APPLIES:
This notice applies to all of the records of your care and billing for care that are created at Nursing Home, whether made by Nursing Home personnel, your independent personal doctor or other independent health care personnel, who are responsible for their own actions. These records are the physical property of and are owned by Nursing Home. Your personal doctor or other independent health care personnel treating you
may have different policies regarding confidentiality and disclosure of your medical information that is created in their office or locations other than Nursing Home.
WHAT THIS NOTICE DOES:
This notice will tell you about the ways in which the people listed above may use and disclose medical information about you at Nursing Home. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information at Nursing Home.
We are required by law to:
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to persons who are involved in taking care of you at Nursing Home, such as independent doctors and other independent health care professionals who are permitted to treat or care for Residents of Nursing Home, nurses, nurses’ aides and other Nursing Home personnel or to students and faculty who are participating in clinical teaching experiences at Nursing Home. For 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. Different departments of the Nursing Home also may share medical information about you in order to coordinate what you need, such as therapy, lab work and activities. We also may need to disclose medical information about you to people outside Nursing Home who may be involved in your medical care before, during or after you leave Nursing Home, such as family members, or others who provide services, such as hospitals, therapists, or medical specialists, which are part of your care. We may provide, without your consent, medical information about you in connection with any transfer of you to obtain health care elsewhere. We will otherwise only disclose medical information about you to people outside Nursing Home, who are not currently involved in your care at Nursing Home, with your consent, except for disclosures that are required or permitted by law.
For Payment. We may need to use and disclose medical information about you so that the treatment and services you receive at Nursing Home or as given by other providers may be billed to and payment
may be collected from you, Medicare and Medicaid, an insurance company/health plan, or a third party. For example, we may need to give Medicare or Medicaid information about lab work or therapy you received at Nursing Home, so Medicare or Medicaid will pay us or reimburse you for the lab work or therapy. We are permitted by law to disclose the amount of medical information necessary for us to obtain payment for the care and services provided to you. Our disclosure of medical information for the purpose of obtaining payment for the care and services provided to you, may also include our giving information to your family members who are involved in your care, insureds on your policy or help pay for your care.
For Health Care Operations. We may use and disclose medical information about you for Nursing Home operations. These uses and disclosures are necessary to run the Nursing Home and make sure that all of our Residents receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the qualifications and performance of our staff in caring for you. We may also combine medical information about many Nursing Home Residents to decide what additional services the Nursing Home should offer, what services are not needed, and whether improvements can be made. We may also disclose information to nurses, technicians and other Nursing Home personnel, independent doctors and health care professionals who are involved in treatment of Residents at Nursing Home or faculty and students who are having clinical education experiences at Nursing Home for review and learning purposes. We will only disclose, with your consent, medical information about you that identifies you to people outside Nursing Home, who are not currently involved in your care, except for disclosures that are required or permitted by law.
Subject to certain requirements, the Nursing Home may use or disclose protected health information about you in certain limited situations without your prior authorization. These situations include:
Individuals Involved in Your Care. Except as explained below concerning information furnished in connection with the Nursing Home Roster or Directory, we may disclose medical information about you to a friend or family member who is involved in your medical care, unless you are able to and object. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. You can object to these disclosures by telling us that you do not wish any or all individuals involved in your care to receive this information. If you cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to disclose relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.
Nursing Home Roster or Directory. Unless you tell us otherwise, we will include certain limited information about you in the Nursing Home roster or directory while you are a Resident at Nursing Home. This information may include your name, room number and religious affiliation. This directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends and clergy can visit you in the Nursing Home and generally know how you are doing. If you choose not to be listed in the directory, then we may not be able to acknowledge that you are in the Nursing Home to your family, friends, clergy, or delivery people. If you do not want anyone to know this information about you, if you want to limit the amount of information that is disclosed, or if you want to limit who gets this information, you must indicate your choice on the Nursing Home’s Resident Directory Instructions Form.
Research. Under rare circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all Residents who received one medication to those who received another for the same condition. All research projects, however, will require your written consent if the researchers will know who you are.
Medical information about you that has had identifying information removed may be used for research without your consent.
As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law, or other judicial or administrative proceedings.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you, consistent with applicable law and standards of ethical conduct, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat and limited to the information needed.
Organ and Tissue Donation. If you are an organ or tissue donor, we are required by law to provide medical information about you to the person or entity who receives the cadaveric organ, eyes, or tissue donation.
Public Health Risks. We may use or disclose your protected health information for public health activity purposes to a public health authority where permitted under state and federal law. These activities generally include the following:
Surveys and Other Health Oversight Activities. We may disclose without your consent medical information to a health oversight agency when authorized by law. These oversight activities include, for example, audits, investigations (civil, administrative, or criminal), inspections, and licensure or other activities necessary for appropriate healthcare oversight. These activities are necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. The Department of Health and Human Services has authority to inspect nursing homes and to review any records of the current or former Residents of the nursing home unless you object in writing to review of your records. The state ombudsman can review your records with your consent or the consent of your legal representative. Some professional licensing boards, such as the board that governs licensing of physicians, have the right to review your records when investigating a particular physician.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we must disclose medical information about you in response to a court or administrative order. We also may disclose medical information about you in response to a subpoena or other lawful process from someone involved in a dispute by furnishing your medical records or information under seal to the court. The copies of your medical record under seal may only be opened by the judge, the parties to the case, or their attorneys unless a judge orders otherwise.
Law Enforcement. In accordance with state and federal law, we may release your protected health information to a law enforcement official:
Coroners, Medical Examiners, and Funeral Directors. We may release without your consent medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about the identity of Residents at Nursing Home to funeral directors, as authorized by state and federal law, as necessary to carry out their duties.
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 the Nursing Home except as authorized by you in writing, pursuant to a court order, or as required by law. Psychotherapy notes about you will be marked “confidential” in the medical record. Any psychotherapy and/or counseling notes written by the provider for their own use will not be accessed by any employee or stored in the medical record.
Abuse, Neglect or Domestic Violence. Where authorized by state and federal law, we may report information about abuse, neglect or domestic violence to public authorities or other appropriate government authorities that are authorized by law to receive such reports. We will often inform you of the disclosure unless doing so could cause a risk of harm.
Specialized governmental functions. When the appropriate conditions apply, and where required under state and federal law, we may disclose protected health information about you if it relates to military and veterans’ activities, national security and intelligence activities, and protective services for the President.
Inmates. We may, consistent with applicable law, use or disclose protected health information about you as it relates to correctional institutions and law enforcement custodial situations involving you. For example, we may disclose such information, if necessary, for the provision of healthcare to you in a correctional institution.
Emergency. As permitted by federal and state law, we may disclose your protected health information in emergency treatment circumstances involving you.
Except for the general categories of uses and disclosures of protected health information for Treatment, Payment and Health Care Operations and other special situations described above, we must obtain your prior written authorization in order to use or disclose your protected health information.
Marketing / Sale of Protected Health Information. Nursing Home shall be required to obtain your written consent prior to the use or disclosure of your protected health information (i) for marketing purposes, except if the communication is in the form of a face-to-face communication made by Nursing Home to you or in the form of a promotional gift of nominal value provided by Nursing Home, or (ii) in connection with the sale of your protected health information.
There are a limited set of circumstances in which the Nursing Home may use and disclose certain protected health information for fundraising without authorization. Regardless of whether an authorization is required or obtained, Nursing Home must ensure that any fundraising communication provides individual patients with a clear and conspicuous opportunity to opt-out of receiving future fundraising communications.
You may cancel an authorization whenever you choose so long as your withdrawal is in writing. If you cancel your authorization, we will no longer use or disclose protected health information about you for the reasons indicated in the authorization. You understand that we are unable to take back any disclosures we have already made prior to your cancellation.
Uses and disclosures related to your individual protected health information not described in this Notice will be made only after your authorization is obtained.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. If you are a current Resident, you or your representative have the right to inspect your protected health information contained in a “designated record set,” as long as Nursing Home maintains your information, within 24 hours of your request, excluding weekends and holidays. A “designated record set” includes your medical record, billing record, payment, billing and adjudication documents, case management record system and records used to make decisions about you.
If you are a current Resident, you or your legal representative have a right to purchase either hard or electronic copies of your records or any portions of your records on two working days’ advance notice to the facility. If you are no longer a current Resident at the time of your request to inspect or copy your records, the facility must act on the request no later than 30 days after receipt. If records or information are not maintained on-site, the facility has up to 60 days to act on the request. If the facility is unable to respond within the 30 or 60 days, the facility may have a one-time extension of no more than 30 days. The facility must notify the requesting party in writing of the reason/s for the delay and the date when the request will be completed.
To inspect or receive a copy of your records, you must submit your request in writing to the Nursing Home Medical Records Department or the privacy officer at the following address: Peak Resources, Inc. 101 Baines Court, Cary, North Carolina 27511. If you request a copy of the information, we may charge a fee not to exceed the community standard rate for the costs of copying, mailing, or other supplies associated with your request and may collect the fee before providing the copy to you. If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay and will collect the fees, if any, for preparing the summary or explanation.
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 Nursing Home.
To request an amendment, your request must be made in writing and submitted to the Medical Records Department. 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:
If we deny your request, 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.
Right to an Accounting of Disclosures. You have the right to request a list, in either paper or electronic format, of certain disclosures we have made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department or the Nursing Home’s Privacy Officer. Your request must state a time period that may not be longer than six years prior to the request and may not include dates before April 14, 2003. The accounting of disclosures will not include protected health information disclosure made: (i) for your treatment (unless such disclosure is made electronically), (ii) for billing and collection of payment for your treatment (unless such disclosure is made electronically), (iii) for our health care operations (unless such disclosure is made electronically), (iv) to or requested by you, or that you authorized, (v) occurring as a byproduct of permitted uses and disclosures, (vi) made to individuals involved in your care, when the use and/or disclosure relates to certain specialized government functions, or when the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations (please see Section B above); and (vii) part of a limited set of information which does not contain certain information which would identify you.
Your request should indicate in what form you want the list (for example, on paper, or 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. We may collect the fee before providing the list to you.
Right to Request Restrictions. Except where we are required to disclose the information by law, you have the right to request a restriction or limitation on the medical information we use or disclose about you. For example, you could ask that we not use or disclose information about a treatment you had to a family member or friend.
We are not required to agree to your request to restrict use or disclosure of your information within Nursing Home or among the health care professionals currently involved in your care at Nursing Home except with regard to psychotherapy notes. If we do agree, we will comply with your requested restriction unless the information is needed to provide you emergency treatment. Except as permitted or required by law, we will only disclose your confidential medical information to persons outside Nursing Home who are not currently involved in your care at Nursing Home, in accordance with your written authorization.
Further, you have the right to restrict disclosure of your protected health information to your health plan if you pay out-of-pocket and in full for such healthcare items or services provided.
To request restrictions, you must make your request in writing to the Medical Records Department. 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.
Right to Request Confidential Communications. You or your representative 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 by speaking with you in a certain location or contacting your representative at work or at a certain mailing address.
To request communications by certain means, you must make your request in writing to the Medical Records Department and specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to be Informed of Security Breaches. You have the right to and will be notified following a breach of your unsecured protected health information maintained by the Nursing Home. You will be notified about any such breach without undue delay, but in no case later than sixty (60) days after the breach is discovered by Nursing Home.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice or any revised 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 or by contacting the Corporate Privacy Officer at 919- 290-2722.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by this notice will be made only with your written permission or as required by law. 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 purposes that you had authorized in writing. 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.
DISCLOSURE TO HEALTH INFORMATION EXCHANGES
This facility participates in the North Carolina Health Information Exchange Network, called NC HealthConnex, which is operated by the North Carolina Health Information Exchange Authority (NC HIEA). We will share your protected health information, or PHI, with the NC HIEA and may use NC HealthConnex to access your PHI to assist us in providing health care to you. We are required by law to submit clinical and demographic data pertaining to services paid for with funds from North Carolina programs like Medicaid and State Health Plan. We may also share other patient data with NC HealthConnex not paid for with State funds. If you do not want NC HealthConnex to share your PHI with other health care providers who are participating in NC HealthConnex, you must opt out by submitting a form directly to the NC HIEA. Forms and brochures about NC HealthConnex are available in our offices and online at NCHealthConnex.gov. You may also contact our Privacy Office at (919)290-2722. Again, even if you opt out of NC HealthConnex, we still will submit your PHI if your health care services are funded by State programs. Your patient data may also be exchanged or used by the NC HIEA for public health or research purposes as permitted or required by law. For more information on NC HealthConnex, please visit NCHealthConnex.gov/patients.
You can find the opt-out form and other information regarding NCHealthConnex at the back of this handbook.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Nursing Home. The notice will remain in effect for each subsequent visit unless changed. If the notice changes, a copy will be made available to you upon request.
COMPLAINTS: You will not be penalized or retaliated against for filing a complaint.
If you believe your privacy rights have been violated, you may file a complaint with Nursing Home or with the Secretary of the United States Department of Health and Human Services. To file a complaint with Nursing Home, contact the Corporate Privacy Officer, at Peak Resources, Inc., Attn: Privacy Officer, 101 Baines Court, Cary, NC 27511. All complaints must be submitted in writing.
We at Peak Resources are committed to creating an environment “where caring comes to life” by empowering and enabling our staff and residents to achieve their personal best…through our staff’s commitment to Initiative, Teamwork, Empathy, Courtesy and Communication.
Alamance: (336) 228-8394
Brookshire: (919) 644-6714
Charlotte: (704) 749-1100
Cherryville: (704)435-6029
Gastonia : (704) 861-0981
Outer Banks: (252) 441-3116
Pinelake: (910) 947-5155
Shelby: (704)482-5396
Wilmington: (910) 362-3621
Copyright @ 2016 Peak Resources Inc. All rights reserved.
