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Notice of Privacy Practices

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488 West Bankhead Street
New Albany, MS 38652

Effective Date: January 1, 2017

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, please contact 1-662-534-0898 during regular business hours. If necessary, your question may be directed to the Privacy and Security Office, or their designee.

Who will follow this notice: This notice describes our privacy practices and that of the physician members; all employees, staff and other personnel; any volunteers who perform volunteer work in the clinic; any student working under the direct supervision of a provider or nurse practitioner.

Our Pledge Regarding Medical Information:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this health care facility to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this facility. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to keep private medical information that identifies you; give you this notice of our legal duties and privacy practices with respect to medical information about you and follow the terms of the Notice of Privacy Rights currently in effect.

How We May Use And Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. For better understanding, we have provided some examples in each category. 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 doctors, nurses, technicians, medical students, students in other health fields, or other personnel who are involved in taking care of you. 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 dietician if you have diabetes so that the hospital can arrange the appropriate meals if need be. Different departments of the health care facility also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We may disclose information about you to people outside the facility who may be involved in your medical care after you leave the entity, such as members assisting you or other health care members, such as nursing homes, home health care agencies, or medical equipment providers. We also may use your medical information to contact you to check that you are progressing in your recovery. In addition if you receive treatment from an entity that participates in a Health Information Exchange, we will also share your information with the Health Information Exchange. Contact our Privacy Officer for questions or concerns.

  • For Payment. We may use and disclose medical information about you so that the treatment and services you receive at this facility may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may share your information with other health care providers who treat you, such as an ambulance service or a hospital or other consulting physicians who treat you.

    Note on the Right to Request a Restriction. You have the right to request that we do not file a visit with your insurance company. However, there are certain limits on that right: 1) you must pay out-of-pocket for the full cost of the visit. If we cannot unbundle the visit from other services, you will need to pay in full for the entire bundle services. 2) You will have to pay each provider who would otherwise have the right to bill insurance for the services they provided to you. 3) If the final amount of charges cannot be calculated during the time of your visit, you will be asked to pay an estimated amount at the time of the visit and any difference between the final and estimated amount when the final amount is known. If you fail to pay the difference between the final and estimated amount, then we have the right to file the claim with your insurance company.

  • For Health Care Operations. We may use and disclose medical information about you for this facility’s operations. These uses and disclosures are necessary to run the facility and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about our patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, students in other health care fields and other personnel for review and learning purposes. We may also combine the medical information we have with the medical information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care delivery without learning who the specific patients are.

  • Health Information Exchange. This facility participates in one or more health information exchanges. A health information exchange facilitates sharing of information among health care organizations such as hospitals, clinics and other state or federal-mandated reporting organizations.

  •  Photographs. We may photograph patients, including newborn babies, for security and identification purposes. In certain circumstances, we may take photographs to document wounds or changes in wound healing.
  • Patient Satisfaction Surveys. We may use a limited amount of information about you to conduct patient satisfaction surveys by telephone and written communications, including email. If you do not want to receive a patient satisfaction survey, you need to let us know by calling our office at 662-534-0898 and speaking to the Office Manager or the Billing Manager.

  • Health Awareness Materials. We may use your demographic information to send general information to you to create awareness in the community of important health topics.

  • Personal Representative. If you have an advance directive, such as a Durable Power of Attorney for Health Care, or if a court has appointed a guardian for you, we will share information regarding your treatment with your personal representative unless we believe that the sharing of information would jeopardize your health or safety.

  • Appointment Reminders. We may use and disclose your information to contact you as a reminder that you have an appointment for medical care. This practice includes contacting you by mail, telephone, email or text messaging (if you signed up for this service).

  • Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. This includes reviewing your medical information to see if you meet the criteria to be eligible to participate in clinical trials.

  • Health-Related Benefits and Services. We may use and disclose medical information to tell you about health- related benefits or services that may be of interest to you.

  • Email. If you provide us with an email account, we may use that email address to enroll you in WebView, which gives patients direct contact with providers and their own chart information, where they can obtain their results from recent tests, X-rays, etc.. We will also use it for any general communications such as appointment reminders and health awareness materials.


  • Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to

    a friend or family member who is involved with your medical care or payment for services, unless you inform us that you object to such disclosure. (However, you may not use such objection to avoid payment for services by a responsible party.) We may use or disclose information about you to locate and notify your family, personal representative or other person responsible for your care that you are in the hospital, doctor’s office and your general condition. In the event of a disaster, we may disclose medical information about you to an entity assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status and location.

  • Research. Under certain circumstances, we may use and disclose medical information about you for records- based research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the needs with patients’ needs for privacy of their medical information. Before we disclose medical information contained in medical records to a researcher, the project will have been approved through this research approval process and the researcher will have submitted a plan to protect the confidentiality of patient information. We may also contact you about eligibility to participate in a clinical trial.

  • As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

  • To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you 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.

  • Uses and Disclosures Requiring Written Patient Authorization. The following types of uses and disclosures require written authorization from the patient: 1) Psychotherapy notes, except for uses or disclosures for carrying out treatment, payment, or health care operations, as required by law, health oversight activities, or to avert a serious threat to health or safety. 2) Marketing, excluding face to face communications and promotional gifts of nominal value, and 3) Any disclosure of your personal information which constitutes a sale under regulatory definitions because we would receive something of financial value in exchange for providing your personal information. Additionally, other types of uses and disclosures not described in this Notice of Privacy Practices will be made only with your written authorization. After providing written authorization, you may revoke the authorization, except to the extent we have already taken action upon the authorization or unless the authorization was obtained as a condition of obtaining insurance coverage.


  • Access by Parents. Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the law for the state of Mississippi and will make disclosures following such law.

  • Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

  • Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

  • Medical Surveillance of the Workplace. If you are an employee who is being evaluated at the request of your employer for medical surveillance of the workplace or in relation to a work-related illness or injury, we may share information obtained from such evaluation with your employer.

  • Public Health Risks. We may disclose medical information about you for public health activities. These activities

    generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report suspected child or adult abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

  • Health Oversight Activities. We may disclose medical information to a health oversight agency for activities

    authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil right and other laws, regulations, and regulatory advice. We may also disclose medical information to lawyers or consultants who are providing services to our facility regarding a legal or regulatory matter.

  • Lawsuit and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if we receive written assurances that the party seeking your medical information has made efforts to tell you about the request or to obtain an order protecting the information requested. We may use your medical information to defend a legal action against this facility.

  • Law Enforcement. We may release medical information if asked to do so by a law enforcement official as follows: In response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct at the location of the facility; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity; description or location of the person who committed the crime.

  • Coroners, Medical Examiners and Funeral Directors. We may release 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 patients to funeral directors as necessary to carry out their duties.

  • National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

  • Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

  • 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 release would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.


    You have the following rights regarding medical information we maintain about you:

  • Right to Inspect and Copy. You have the right to inspect and obtain a copy of medical information used to make

    decisions about your care. Usually, this generally includes medical and billing records. To inspect or request a copy of medical information used to make decisions about you, you must complete a valid, HIPAA compliant authorization form and submit it to the facility. 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. You also have the option to receive an electronic copy of your records. Patients accessing the Patient Portal/Webview may logon to their medical record and print at any time with a secure logon and password. There is no charge associated with the Patient Portal.

  • Note on Limitation of the Right to Access. We may deny your request to inspect and obtain a copy in certain, limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional 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 the health care provider whose records you are seeking to amend. To request amendment, your

request must be made in writing and submitted to the facility. 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: 1) was not created by us, 2) unless the person that created the information is no longer available to make the amendment, 3) is not part of the medical information kept by this health care provider, 4) is not part of the information which you would be permitted to inspect and copy, or 5) is accurate and complete.

  • 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 for reasons other than treatment, payment or health care operations. For example, an accounting of disclosures would include disclosures that we are required by law to make, such as reporting communicable diseases to the county health department. To request this accounting of disclosures, you must submit your request in writing to the Privacy & Security Officer, Internal Medicine & Pediatric Clinic of New Albany, 488 W. Bankhead St., New Albany, MS 38652. Your request must state a time period, which may not be longer than six years prior to the date of your request. 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. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or if disclosure is required by law. To request restrictions, you must make your request in writing to us. 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.

  • 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. However, you must provide us with an address to which we can send all written correspondence, including your bill. At the time of registration, you will be requested to provide one mailing address and one phone number which are acceptable to you for receiving communications from us. You may request a change to your confidential communications address and phone number by submitting a written request to us. We will not ask you the reason for your request. We will accommodate reasonable requests. Your request must specify how or where you wish to be contacted.

  •  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. You may also obtain a copy of this notice at www.impcna.com.


  • We are required by law to maintain the privacy of Protected Health Information, provide you with notice of our legal duties and privacy practices, and to notify affected individuals following a breach of unsecured Protected Health Information.

  • We are required to abide by the terms of the Notice of Privacy Practices currently in effect.


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 on-site as well as at www.impcna.com. We will also provide you with an updated copy of the Notice upon request. The Notice will contain the effective date on the top of the first page.


If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the Department of Health and Human Services. To file a privacy complaint with the facility, contact 1-662-534- 0898 ext. 202, or submit your complaint in writing to the Privacy and Security Officer, Internal Medicine & Pediatric Clinic of New Albany, 488 W Bankhead St, New Albany, MS 38652.

You will not be penalized for filing a complaint.


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 authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, 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 authorization and that we are required to retain our records of the care that we provided to you.


Call us at 662.534.0898

118 Fairfield Drive
New Albany, MS 38652

Normal Business Hours
Mon-Fri: 8:00AM-5:00PM
Extended Hours
Mon-Fri: 7:00AM-8:00 AM
Sat: 8:30AM-3:00PM
Pay Your Bill Here

Saturday Doctor Schedule
December 2: Dr. Scott
December 9: Dr. Rhinewalt
December 16: Leanne Lewis and Katie Minga
December 23: Closed
December 30: Closed