Notice of Privacy Practices

Effective Date: 02/02/2018
Revised Date: 11/01/2025

Notice of Privacy Policy 11/1/25 – English [73.15 KB]

Aviso sobre Prácticas de Privacidad 11/1/25 – Spanish [68 KB]

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.

Who Will Follow This Notice: This notice summarizes the privacy practices of the members of Ballad Health’s Affiliated Covered Entity (ACE), which are health care facilities and other health care entities that are under common ownership or control and share privacy policies and procedures. As the members of Ballad Health’s ACE may change over time, please use this link to view the current list of Ballad Health’s ACE members.

This notice also applies to members of our medical staff to the extent that they provide services at Ballad Health facilities. We may share your medical information with members of the medical staff as necessary to carry out joint treatment, payment, or health care operations activities.

Our Pledge to You: We understand that your health information is personal, and we are committed to protecting its privacy. We are required by law to:

• Maintain the privacy of your health information.
• Give you this notice of our legal duties and privacy practices regarding your health information.
• Follow the terms of our Notice of Privacy Practices that are currently in effect; and
• Notify you following a breach of your unsecured health information

Your rights regarding health information about you

Right to inspect and copy: You have the right to request to inspect and obtain a paper or electronic copy of the health information that may be used to make decisions about your care or payment, and to request that an electronic copy of your electronic health record be forwarded to a third party of your choice. However, under certain circumstances and, if permitted by law, we may deny your request. To inspect and obtain a copy of your health information, you must submit your request in writing. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request, or less as required by state law. There may be reasonable, cost-based fees for the costs of copying, mailing or other supplies associated with your request. 

Right to amend: If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information as long as it is kept by Ballad Health. To request an amendment, your request must be made in writing and provide a reason that supports your request. Ask us how to submit this request. We may deny your request under certain circumstances. You will be informed of the decision regarding any request for amendment of your health information within 60 days and, if we deny your request for amendment, we will provide you with information regarding your right to respond to that decision.

Right to an accounting of disclosures: You have the right to request a list of certain disclosures we make of your health information. We will include all disclosures except those for treatment, payment, health care operations, and certain other disclosures (such as those you asked us to make). To request this list of  disclosures, you must submit your request in writing to the healthcare provider or facility. Your request must state a time period for which the accounting of disclosures is sought, which cannot be longer than six years prior to the date on which your request for accounting is made. 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 but will notify you of the cost involved and offer you the chance to withdraw or modify your request before any costs are incurred.

Right to request restrictions: You have the right to request a restriction on the health information we use or disclose about you for treatment, payment, health care operations, to persons involved in your care or payment, or disclosures for disaster relief purposes. We are not required to agree to a request for restrictions, other than a request that we not disclose information to a health plan for payment or health care operations where the request relates only to a health care item or service for which we have been paid in full. We will notify you if we don’t agree to your request for restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the healthcare provider or facility. 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 health plan.

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 contact you only by mail or at work. Your request must be in writing and specify how or where you wish to be contacted and to what address we may send bills for payment for services provided to you. We will accommodate reasonable requests.

Right to a paper copy of this notice. Right to a paper copy of this notice. You have the right to a copy of this 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 also obtain a copy of this notice at our website BalladHealth.org.

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make reasonable efforts to ensure the person has this authority and can act for you before we take any action.

How your health information may be used and disclosed without your authorization: The following describes different ways that Ballad Health is permitted to use and disclose health information that identifies you. If you receive services from Woodridge Hospital, Strong Futures, or Thomas E. Renfro Community Clinic, then information that identifies that you have or had a substance use disorder (Substance Use Disorder Records) are subject to additional restrictions that are addressed below. Note that the federal medical privacy law commonly known as HIPAA only applies to certain entities (certain health care providers, health plans, and entities acting on their behalf). Accordingly, health information that is disclosed as described below in accordance with HIPAA may be subject to redisclosure by the recipient and no longer protected by HIPAA. For example, if we disclose your health information as required by a court order, the information may no longer be protected by HIPAA.

Treatment: We may use health information to treat you or provide you with healthcare services. For example, we may tell your primary care physician about the care we provided you or give health information to a specialist to provide you with additional services. We generally will not disclose Substance Use Disorder Records for treatment purposes without your consent, except in a bona fide medical emergency in which your consent cannot be obtained.

Payment: We may use and disclose health information so that we or others may bill or receive payment from you, an insurance company or a third party for the treatment and services provided to you. For example, we may disclose your health information to an ambulance company, so that the ambulance company can receive payment for services provided to you. We generally will not disclose Substance Use Disorder Records for payment purposes without your consent.

Healthcare operations: We may use and disclose health information for healthcare operations and administrative purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may share information with doctors, nurses, medical students, and other personnel for learning purposes. We generally will not disclose Substance Use Disorder Records for health care operations purposes without your consent.

Health information exchange: Ballad Health participates in one or more electronic Health Information Exchange (HIE) networks. Through these health information exchanges, your information will be electronically available to other health care providers and other entities. These entities can access your Ballad Health’s health information for your treatment or other permitted purposes. If you have questions about Ballad Health’s involvement in electronic health information exchange, please contact our Privacy Officer in the Corporate Compliance Department at 423-302-3345 or the AlertLine at 1-800-535-9057. We generally will not disclose Substance Use Disorder Records through health information exchange without your consent, except for treatment purposes in a bona fide medical emergency in which your consent cannot be obtained.

Facility directory: We may list your information in our facility directory, unless you ask us not to. If you are at Woodridge Hospital, we generally will not disclose your presence at the facility without your consent.

Fundraising activities: We may use and disclose certain limited health information to our Foundation so that it may contact you regarding fundraising activities. This may include information that identifies that you were seen by a department or physician that specialized in substance use disorder services. You have the right to notify the Foundation at 423-302-3151 to request not to receive fundraising information.

Individuals involved in your care or payment for your care: If you do not object, or we reasonably infer, based on professional judgment, that you do not object to the disclosure, we may disclose relevant health information to a family member, friend, or other person involved in your medical care or who helps pay for your care. We may also disclose health information to a personal representative, who is a person who has legal authority to make healthcare decisions on your behalf. We generally will not disclose Substance Use Disorder Records to a family member, friend, or other person involved in your medical care or payment without your consent.

Business associates: We may disclose health information to our business associates who perform functions on our behalf or provide us with services, if the information is necessary for such functions or services.

Research: Under certain circumstances, we may use and disclose health information for research purposes provided that we comply with applicable federal and state legal requirements.

Other purposes: We may use or disclose health information about you for other reasons:

• In a disaster relief situation (except for Substance Use Disorder Records).
• When required by international, federal, state or local law, including a request by the Secretary of the Department of Health and Human Services to see that we are complying with federal privacy law (additional restrictions may apply to disclosures of Substance Use Disorder Records).
• To avert or reduce a serious threat to health or safety of the public or another person (except for Substance Use Disorder Records).
• For special government functions such as national security and intelligence activities, including presidential protective services (except for Substance Use Disorder Records).
• For a member of the Armed Forces (domestic or foreign), we may disclose your medical information as required by military command authorities (except for Substance Use Disorder Records).
• In response to a court or administrative order, subpoena or other lawful process (except that a specialized type of court order generally is required before we will disclose Substance Use Disorder Records).
• To a law enforcement official for law enforcement purposes provided we comply with applicable legal restrictions (except for Substance Use Disorder Records).
• To report suspected abuse, neglect, or domestic violence.
• If you are an inmate, to the correctional institution or law enforcement official (except for Substance Use Disorder Records).
• To an organ donation bank or to facilitate organ or tissue donation and transplantation (except for Substance Use Disorder Records).
• To workers’ compensation or similar programs for work-related injuries or illness to the extent necessary to comply with laws related to these programs (except for Substance Use Disorder Records).
• For public health activities such as to prevent or control disease, injury or disability; to report births and deaths; to notify a person who may have been exposed or who may be at risk of spreading a disease; or reporting information to the Food and Drug Administration (FDA) if you experience an adverse reaction from any drugs, supplies or equipment (except for Substance Use Disorder Records).
• To health oversight agencies for activities authorized by law (except for Substance Use Disorder Records).
• To a coroner/medical examiner as authorized by law to identify a deceased person or determine cause of death (except for Substance Use Disorder Records).
• To funeral directors to carry out their duties (except for Substance Use Disorder Records).

Uses and disclosures of medical information which require your authorization: Uses and disclosures of health information that are not discussed by this notice or required by law will only be made with your written permission. Your written authorization will typically be required for most uses and disclosures of psychotherapy notes, most uses and disclosures for marketing and most arrangements involving the sale of health information.

Further restrictions on substance use disorder records: We generally will not use or disclose substance use disorder treatment records received from programs that hold themselves out as providing substance use disorder services (including programs outside of Ballad Health) in civil, criminal, administrative, or legislative proceedings against you without your consent or a special type of court order that is specific to substance use disorder records and is accompanied by a subpoena or other legal requirement compelling disclosure.

How you may revoke your authorization: If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. Your request to revoke your authorization must be sent to our Privacy Officer or Corporate Compliance Officer.

Changes to this notice: We reserve the right to change this notice and the revised or changed notice will be effective for health 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 at Ballad Health. The effective date is noted on the first page. You may request a copy of the new notice be sent to you in the mail or electronically.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.

To file a complaint with us, please contact our Privacy Officer at 423-302-3345 or the Ballad Health AlertLine at 1-800-535-9057. There will be no retaliation against you for filing a complaint.

Contact: If you have questions or would like additional information, you may contact the Privacy Officer in the Corporate Compliance Department at 423-302-3345 or ComplianceQuestions@balladhealth.org or the AlertLine at 1-800-535-9057.

This notice describes:

• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION
• YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH THE PRIVACY OFFICER IN THE CORPORATE COMPLIANCE DEPARTMENT AT 423-302-3345 OR ComplianceQuestions@balladhealth.org IF YOU HAVE ANY QUESTIONS.

Confidentiality of substance use disorder patient records: The above-identified Ballad Health facilities, units, or staff (programs) specialize in providing substance use disorder treatment. Federal law and regulations provide additional privacy protection to information about substance use disorder treatment generated by these programs. Accordingly, in addition to the privacy protections described in the Ballad Health Notice of Privacy Practices, these additional restrictions apply to substance use disorder treatment records generated by programs. These restrictions do not apply to substance use disorder information that is not generated by a program, such as substance use disorder information generated by a primary care physician.

Generally, the programs may not identify that you receive services at a program, or disclose any information from a program identifying you as receiving substance use disorder treatment (collectively, “Substance Use Disorder Records”) unless:

1. You consent in writing:
2. The disclosure is allowed by a court order specific to Substance Use Disorder Records; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

The programs must obtain your consent for most uses and disclosures of your Substance Use Disorder Records for treatment, payment, or health care operations. For example, the programs must obtain your consent to disclose your Substance Use Disorder Records to your primary care physician. You may provide a single consent for all future uses or disclosures of your Substance Use Disorder Records for treatment, payment, and health care operations purposes. The programs may only make uses and disclosures of your Substance Use Disorder Records that are not listed in this notice with your written consent. You may revoke a consent in writing at any time, except to the extent that the program or a recipient of your substance use disorder has already acted in reliance on your consent. Your request to revoke your consent must be sent to our Privacy Officer or Corporate Compliance Officer.

Substance Use Disorder Records, or testimony relaying the content of such records, may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in the federal law governing confidentiality of substance use disorder records at 42 C.F.R. part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed.

Substance Use Disorder Records that are disclosed to another program governed by 42 C.F.R. part 2 or to a HIPAA covered entity (including a portion of Ballad Health that is not a substance use disorder treatment program) or business associate pursuant to your written consent for treatment, payment, and health care operations may be further disclosed by the recipient (including Ballad Health), without your written consent, to the extent HIPAA regulations permit such a disclosure.

A program may use or disclose information that identifies that you were seen by a department or physician that specializes in substance use disorder services for fundraising purposes. You have the right to notify Ballad Health’s Foundation at 423-302-3151 to request not to receive fundraising information.

Federal law and regulations governing Substance Use Disorder Records do not protect:

• Any information about a crime committed by a patient either at the treatment program or against any person who works for the program, or about any threat to commit such a crime.
• Any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Your rights regarding your substance use disorder treatment records: You have the following rights with respect to your substance use disorder treatment records:

• The right to request restrictions on disclosures made with your prior consent for purposes of treatment, payment, and health care operations.
• The right to request and obtain restrictions of disclosures of Substance Use Disorder Records to your health plan for those services for which you have paid in full.
• To the extent that your Substance Use Disorder Records are disclosed to an intermediary, such as a Health Information Exchange network, for further disclosure, you have a right to a list of disclosures by the intermediary for the past three years.
• You have a right to obtain a paper or electronic copy of this notice upon request.
• You have a right to discuss this notice with the Privacy Officer.
• You have the right to elect not to receive fundraising communications.

For information about the programs’ duties with respect to privacy, how to file a complaint regarding a program, and contact information for further information about this notice, please see the sections of the Ballad Health Notice of Privacy Practices titled “Our Pledge to You,” “Complaints,” and “Contact.”

Access notice of availability of language assistance and auxiliary aids and services 

Changes to This Notice:  We reserve the right to change this notice and the revised or changed notice will be effective for health 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 at Ballad Health. The effective date is noted on the first page. You may request a copy of the new notice be sent to you in the mail or electronically.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.

To file a complaint with us, please contact our Privacy Officer at 423-302-3345 or the Ballad Health AlertLine at 1-800-535-9057. There will be no retaliation against you for filing a complaint.

Contact: If you have questions or would like additional information, you may contact the Privacy Officer in the Corporate Compliance Department at 423-302-3345 or the AlertLine at 1-800-535-9057.

Discrimination Is Against the Law

Ballad Health complies with federal civil rights laws and does not discriminate, exclude people, or treat them differently because of age, race, color, national origin, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression.

Ballad Health provides qualified sign language and oral interpreters, and other auxiliary aids and services free of charge for patients, family members, and companions, who are deaf or hard of hearing, have speech disabilities, are blind or have low vision. Ballad Health also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

To request auxiliary aids or services, please speak to your nurse or other caregiver, ask for the House Supervisor, or contact us at 423-302-3404.

If you believe that Ballad Health has failed to provide these services or discriminated on the basis of age, race, ethnicity, religion, color, national origin, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression, you can file a grievance with the Corporate Compliance Officer (Civil Rights Coordinator) in writing at 400 N. State of Franklin Rd., Johnson City, TN 37604 or by phone at 423-302-3345 or toll free at 1-800-535-9057. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html. 

If you need assistance with filing a complaint, contact the Non-Discrimination Coordinator at 423-302-3404.