Privacy Statement / Identity Theft Protection


The following categories describe ways Cumberland Family Care, PC uses and discloses medical information. Not every possible use or disclosure will be listed. However, the different ways for which this practice may use and disclose information should fall within one of these categories.

Uses and Disclosures

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Your health care information may also be disclosed to students, interns and residents while clinically rotating through our facility. 

: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.



Effective January 1, 2012 the policy regarding overdue balances will be changing as indicated below. 
 Any patient account(s) receiving three notification letters indicating a balance that is 60 days overdue may be subject to discharge from the practice due to multiple non-payment notices for medical services rendered.


Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of Cumberland Family Care, PC. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Health Oversight Activities: Your medical information be disclosed to a health oversight agency for activities authorized by law. For example, audits, investigations, inspections, and licenser.

Coroners, Medical Examiners, and Funeral Directors: Your medical information may be released to a coroner or medical examiner. For example, to determine the cause of death.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This is necessary for the institution to provide you with health care, protect the health and safety of you and others, and the safety and security of the correctional institution. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

National Security, Intelligence Activities and Protective Services for the President and Others: Your medical information will be released to authorized federal officials, other national security personnel, and for protection of the President as authorized by law.

Individuals Involved in Your Care: With your permission, your medical information may be released to a family member, guardian or other patient representative involved in your care. Please inform us if you authorize for your medical information to be released to the above mentioned. Restrictions on information released must also be specified. For example, you inform the nurse that you would like for your spouse to have to your medical information. 

Appointment Reminders:Your health information will be used by our staff to send you appointment reminders by phone, mail, or e-mail. 

Individual Rights - You have certain rights under the federal privacy standards. These include:
The right to request restrictions on the use and disclosure of your Protected Health Information (PHI)

The right to receive confidential communications concerning your medical condition and treatment

The right to inspect and copy your (PHI)

The right to receive an accounting of how and to whom your (PHI) has been disclosed

The right to receive a printed copy of this notice 

Cumberland Family Care, PC Duties
We comply with the law by maintaining the privacy of your protected health information and to provide you with this notice of privacy practices. We are committed to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. We will post a current copy of the notice with the effective date. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information (PHI) we maintain.
Requests to Inspect Protected Health Information (PHI)
You may inspect or have a copy of your health information that has been created by our office(your medical record).  You must complete our medical record release form.  You may obtain a form to request a copy of your record  by contacting the Medical Records Supervisor, the Privacy Officer, or front desk personnel. Your request will be reviewed and will be approved unless there are legal or medical reasons to deny the request. 
Complaints and Contacts
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Cumberland Family Care, PC
Attn: Privacy Officer
457 Vista Drive
Sparta, TN 38583
(931) 738-3383
Effective Date
This Notice is effective on or after April 14, 2003.

Dev. 3.03.03 
Rev. 4.01.09 

Identity Theft Protection
New Federal laws called the “Red Flag Rules” are effective June 1, 2009.  These rules are in place to protect people from identity theft
In compliance with the Red Flag rules AND to protect you as a patient at Cumberland Family Care, we we are now inserting your photo in your confidential medical record.  Your permission for a photo to be taken will be noted in our software system along with the date.  All patients age 2 and up should have a photo in their medical record to protect confidential health information and prevent identity theft.
You will be asked by Reception to have your photograph taken. The process will take approximately 1 minute and is conducted at the counter.  It is very important for you to protect yourself from Identity Theft and this is one way we can help you.  Please note that patients who do not have a photo inside their medical record may be asked for another type of photo identification at check-in.