Privacy Statement

Ralph Scott Lifeservices, Inc.NOTICE OF PRIVACY PRACTICES

Revised to reflect the 2013 HIPAA/HITECH Omnibus Final Rule

Effective June 15, 2016


Ralph Scott Lifeservices values your privacy, and we are committed to protecting personal information, including protected health information that we collect in order to serve you better in our program.

The collection, use, and disclosure of certain nonpublic information are regulated by law [45 CFR 164.520 and NCGS 122C 52-56].

In accordance with NC General statute 130 A – 143 and Substance abuse information (42CFR Part 2), individuals will have to authorize or decline to authorize release of information which contains HIV/AIDS information and Substance abuse information.

This notice is for your information only and requires no action on your part.  It will inform you about the types of information we collect and how it may be disclosed.  This does not reflect a change in the way we have handled your information in the past.

 Protected health information (PHI) means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you.

This notice also will tell you about your rights and our duties with respect to the health information about you.  In addition, it will tell you how to complain if you think we have violated your privacy rights.


 We collect information about you from the following sources:

  • applications and/or other forms completed by you;
  • information from the COC, the MCO, and the Department of Social Services,
  • information we learn from providing services to you;
  • information from doctors and hospitals related to your health care;
  • information about your income from employers, Social Security Administration;
  • information about your finances from banking institutions; and
  • information from previous service providers.


 We will disclose only protected health information with your (or your guardian’s, if applicable) written consent, and as permitted by law without your consent, to others as necessary.  We disclose the information for a number of different purposes.  They are described below.

For Service Provision

For example, we may disclose information to the following types of third parties:

  • your parents or guardian,
  • your doctors, nurses, or hospital,
  • Qualified Professionals,
  • psychologists and other support professionals,
  • social workers,
  • direct support staff,
  • your day program,
  • the COC or MCO,
  • others requested or authorized by you.

We may share this information in order to coordinate needed services, such as the coordination of residential and day services.  We also may share information to plan for your services and to train our staff.  We may use the information for managing our organization more efficiently, for accreditation, for licensing, or for continuing quality improvement.

For Payment

We may disclose information about you so we can be paid for the services we provide to you.  This can be Medicaid, the COC, the MCO, or other third party payor.  We may disclose information in order to be reimbursed and in order to determine your eligibility for services.

For Service(s) Selection

Any use and disclosure of protected health information about you by us to communicate about RSL services to aid in your service selection will be done only with your written authorization.  Further, we do not sell information or otherwise make our list of program participants available to outside entities.

RSL Directory

We may include your name, the location of your residence, your condition described in general terms, and your religious affiliation in our directory while you receive services.  This information, except for your religious affiliation, may be released to people who ask for you by name.  Your religious affiliation may be given to members of the clergy, such as a minister, priest, or rabbi.  If you want to restrict the information we include in the directory, you must notify the President/CEO of Ralph Scott Lifeservices of your objection.

Business Associates

We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  For example, we may use another company to perform billing services on our behalf.  All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Disaster Relief and/or Medical Emergency Personnel

We may use or disclose protected health information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

 Required by Law

We may use or disclose protected health information about you when we are required to do so by law.  This may include orders from

  • law enforcement,
  • Department of Social Services
  • Public Health Department,
  • State regulatory agencies,
  • legal system (summons or subpoena), or
  • those agreed to by you or your personal representative or authorized by law and webelieve the disclosure is necessary to prevent serious harm to you or to someone else.

 Health Oversight Activities

We may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure, or disciplinary actions.  These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.

Funeral Directors

We may disclose information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death.

Worker’s Compensation

We may disclose health information about you to the extent necessary to comply with worker’s compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.

Other Uses and Disclosures

Other uses and disclosures will be made only with your (or your guardian’s, if applicable) written authorization.  You may revoke such an authorization at any time by notifying the Associate Director or Director of CQI in writing of your desire to revoke it.  However, if you revoke such an authorization, it will not have any effect on actions taken by us in reliance on it prior to the evocation.


We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.  Any use of HiTech means of transmission or reception of information will be done with legal and required security measures to protect your information.  If any breach of security should occur, RSL will notify the parties affected as required by law.


 The following rights may be exercised by contacting your Coordinator, Associate Director, or the RSL Privacy Officer:

  • right to request restrictions,
  • right to receive confidential communications,
  • right to inspect and copy health information about you,
  • right to amend health information about you,
  • right to an accounting of disclosures made after April 13, 2003,
  • right to get notice of a breach upon breach of any of your unsecured PHI.


You have the right to obtain a copy of our Notice of Privacy Practices, either paper or electronic (if available).  We will provide reasonable accommodation to persons with disabilities under the ADA.  For example, if you need the notice to be read to you, we will do so.



We are required by law to maintain the privacy of protected health information about you and to provide individuals with notice of our legal duties and privacy practices.  We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

 Our Right to Change the Notice of Privacy Practices

We reserve the right to change this Notice of Privacy Practices.  We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.


A copy of our Notice of Privacy practices is posted in each location rented, owned, or managed by RSL where services are provided and at the RSL administrative office.  A copy of the current notice also will be posted on our web site.

You may obtain a copy of the current Notice of Privacy Practices by contacting your Coordinator or Associate Director.


You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with us, contact your Associate Director or the RSL Privacy Officer.  All complaints should be submitted in writing.  We will help you with this if you need it.

To file a complaint with the United States Secretary of health and Human Services, send your complaint to him/her in care of the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201.

 You will not be retaliated against for filing a complaint.


If you have any questions or want more information concerning this Notice of Privacy Practices, please, write to—                                                            or call—

Privacy Officer                                                          (336) 227-1011

Ralph Scott Lifeservices, Inc.

408 West Trade Street

Burlington, NC 27217



Original notice effective April 14, 2003

Revised and updated notice effective May 10, 2010

Revised and updated notice effective May 15, 2012

Revised and updated notice effective July 15, 2014

Revised and updated notice effective June 15, 2016