• We may contact you
to provide appointment reminders for treatment or medical care.
• We may contact you
to tell you about or recommend possible treatment alternatives or other
health-related benefits and services that may be of interest to you.
• We may disclose to
your family or friends or any other individual identified by you protected
health information directly relevant to such person’s involvement with your
care or payment for your care. We may
use or disclose your protected health information to notify, or assist in the
notification of, a family member, a personal representative, or another person
responsible for your care of your location, general condition or death. If you are present or otherwise available,
we will give you an opportunity to object to these disclosures, and we will not
make these disclosures if you object.
If you are not present or otherwise available, we will determine whether
a disclosure to your family or friends is in your best interest, taking into
account the circumstances and based upon our professional judgment.
• When permitted by
law, we may coordinate our uses and disclosures of protected health information
with public or private entities authorized by law or by charter to assist in
disaster relief efforts.
• We will allow your
family and friends to act on your behalf to pick-up filled prescriptions,
medical supplies, X-rays, and similar forms of protected health information,
when we determine, in our professional judgment, that it is in your best
interest to make such disclosures.
• We may contact you
as part of our efforts to market our practice’s services as permitted by
applicable law.
• Subject to
applicable law, we may make incidental uses and disclosures of protected health
information. Incidental uses and
disclosures are by-products of otherwise permitted uses or disclosures which
are limited in nature and cannot be reasonably prevented.
• [We may use or disclose your protected
health information for research purposes, subject to the requirements of
applicable law. For example, a research
project may involve comparisons of the health and recovery of all patients who
received a particular medication. All
research projects are subject to a special approval process which balances
research needs with a patient’s need for privacy. When required, we will obtain a written authorization from you
prior to using your health information for research.]
• We will use or
disclose protected health information about you when required to do so by
applicable law.
• [Note:
In accordance with applicable law, we may disclose your protected health
information to your employer if we are retained to conduct an evaluation
relating to medical surveillance of your workplace or to evaluate whether you
have a work-related illness or injury.
You will be notified of these disclosures by your employer or the Practice
as required by applicable law.]
SPECIAL SITUATIONS
Subject to the requirements
of applicable law, we will make the following uses and disclosures of your
protected health information:
• Organ and Tissue Donation. If you are an organ donor, we may release
health information to organizations that handle organ procurement or organ, eye
or tissue transplantation or to an organ donation bank, as necessary to
facilitate organ or tissue donation and transplantation.
• Military and Veterans. If you are a member of the Armed Forces, we
may release health information about you as required by military command
authorities. We may also release health
information about foreign military personnel to the appropriate foreign
military authority.
• Worker’s Compensation. We may release health information about you
for programs that provide benefits for work-related injuries or illnesses.
• Public Health Activities. We may disclose health information about you
for public health activities, including disclosures:
* to prevent or control disease, injury or disability;
* to report births
and deaths;
* to report child
abuse or neglect;
* to persons subject
to the jurisdiction of the Food and Drug Administration (FDA) for activities
related to the quality, safety, or effectiveness of FDA-regulated products or
services and to report reactions to medications or problems with products;
* 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 that an adult patient has been
the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when
required or authorized by law.
• Health Oversight Activities. We may disclose health information to
Federal or State agencies that oversee our activities. These activities are necessary for the
government to monitor the health care system, government benefit programs, and
compliance with civil rights laws or regulatory program standards.
• Lawsuits and Disputes. If you are involved in a lawsuit or a
dispute, we may disclose health information about you in response to a court or
administrative order. We may also
disclose health information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute, but
only if the Practice is given
assurances that efforts have been made by the person making the request to tell
you about the request or to obtain an order protecting the information
requested.
• Law Enforcement. We may release health information if asked
to do so by a law enforcement official:
* 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 under certain limited circumstances;
* About a death we
believe may be the result of criminal conduct;
* About criminal
conduct on our premises; and
* In emergency
circumstances, to report a crime, the location of the crime or the victims, or
the identity, description or location of the person who committed the crime.
• Coroners, Medical Examiners
and Funeral Directors. We may
release health information to a coroner or medical examiner. Such disclosures may be necessary, for
example, to identify a deceased person or determine the cause of death. We may also release health information about
patients to funeral directors as necessary to carry out their duties.
• National Security and
Intelligence Activities. We may
release health information about you to authorized Federal officials for
intelligence, counterintelligence, or other national security activities
authorized by law.
• Protective Services for the
President and Others. We may
disclose health information about you to authorized Federal officials so they
may provide protection to the President or other authorized persons or foreign
heads of state or may 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
health 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.
• Serious Threats. As permitted by applicable law and standards
of ethical conduct, we may use and disclose protected health information if we,
in good faith, believe that the use or disclosure is necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the
public or is necessary for law enforcement authorities to identify or apprehend
an individual.
Note: HIV-related information, genetic information, alcohol and/or
substance abuse records, mental health records and other specially protected
health information may enjoy certain special confidentiality protections under
applicable State and Federal law. Any
disclosures of these types of records will be subject to these special
protections.
OTHER USES OF YOUR HEALTH
INFORMATION
Other uses and disclosures of
protected health information not covered by this notice or the laws that apply
to us will be made only with your permission in a written authorization. You have the right to revoke that authorization
at any time, provided that the revocation is in writing, except to the extent
that we already have taken action in reliance on your authorization.
YOUR RIGHTS
1. You have the right to request restrictions on our uses
and disclosures of protected health information for treatment, payment and
health care operations. However, we are
not required to agree to your request.
To request a restriction, you must make your request in writing to the
Practice’s Privacy Officer.
2. You have the right to reasonably request to receive
confidential communications of protected health information by alternative
means or at alternative locations. To
make such a request, you must submit your request in writing to the Practice’s
Privacy Officer.
3. You have the right to inspect and copy the protected health
information contained in your medical and billing records and in any other
Practice records used by us to make decisions about you, except:
(i) for psychotherapy notes, which are notes that have been
recorded by a mental health professional documenting or analyzing the contents
of conversations during a private counseling session or a group, joint or
family counseling session and that have been separated from the rest of
your medical record;
(ii) for information compiled in reasonable anticipation of, or
for use in, a civil, criminal, or administrative action or proceeding;
(iii) for protected health information involving laboratory tests
when your access is restricted by law;
(iv) if you are a prison inmate, obtaining a copy of your
information may be restricted if it would jeopardize your health, safety,
security, custody, or rehabilitation or that of other inmates, or the safety of
any officer, employee, or other person at the correctional institution or
person responsible for transporting you;
(v) if we obtained or created protected health information as
part of a research study, your access to the health information may be
restricted for as long as the research is in progress, provided that you agreed
to the temporary denial of access when consenting to participate in the
research;
(vi) for protected health information contained in records kept
by a Federal agency or contractor when your access is restricted by law; and
(vii) for
protected health information obtained from someone other than us under a
promise of confidentiality when the access requested would be reasonably likely
to reveal the source of the information.
In order to inspect and copy
your health information, you must submit your request in writing to the
Practice’s Privacy Officer. If you
request a copy of your health information, we may charge you a fee for the
costs of copying and mailing your records, as well as other costs associated
with your request.
We may also deny a request
for access to protected health information if:
• a licensed
health care professional has determined, in the exercise of professional
judgment, that the access requested is reasonably likely to endanger your life
or physical safety or that of another person;
• the protected health information makes reference to
another person (unless such other person is a health care provider) and a
licensed health care professional has determined, in the exercise of professional
judgment, that the access requested is reasonably likely to cause substantial
harm to such other person; or
• the request for
access is made by the individual’s personal representative and a licensed
health care professional has determined, in the exercise of professional
judgment, that the provision of access to such personal representative is
reasonably likely to cause substantial harm to you or another person.
If we deny a request for
access for any of the three reasons described above, then you have the right to
have our denial reviewed in accordance with the requirements of applicable law.
4. You have the right to request an amendment to your
protected health information, but we may deny your request for amendment, if we
determine that the protected health information or record that is the subject
of the request:
(i) was not created by us, unless you provide a reasonable
basis to believe that the originator of protected health information is no
longer available to act on the requested amendment;
(ii) is not part of your medical or billing records or other
records used to make decisions about you;
(iii) is not available for inspection as set forth above; or
(iv) is accurate and complete.
In any event, any agreed upon
amendment will be included as an addition to, and not a replacement of, already
existing records. In order to request
an amendment to your health information, you must submit your request in
writing to the Practice’s Privacy Officer, along with a description of the
reason for your request.
5. You have the right to receive an accounting of
disclosures of protected health information made by us to individuals or
entities other than to you for the six years prior to your request, except for
disclosures:
(i) to carry out treatment, payment and health care operations
as provided above;
(ii) incident to a use or disclosure otherwise permitted or
required by applicable law;
(iii) pursuant to a written authorization obtained from you;
(iv) to persons involved in your care or for other notification
purposes as provided by law;
(v) for national security or intelligence purposes as provided
by law;
(vi) to correctional institutions or law enforcement officials as
provided by law;
(vii) as part of a limited data set as provided by law; or
(viii) that occurred prior to April 14, 2003.
To request an accounting of
disclosures of your health information, you must submit your request in writing
to the Practice’s Privacy Officer. Your
request must state a specific time period for the accounting (e.g., the past
three months). The first accounting you
request within a twelve (12) month period will be free. For additional accountings, we may charge
you for the costs of providing the list.
We will notify you of the costs involved, and you may choose to withdraw
or modify your request at that time before any costs are incurred.
COMPLAINTS.
If you believe that your
privacy rights have been violated, you should immediately contact the Practice’s Privacy Officer. We will not take action against you for
filing a complaint. You also may file a
complaint with the Secretary of Health and Human Services.
CONTACT PERSON
If you have any questions or
would like further information about this notice, please contact the Practice’s
Privacy Officer at 516-663-2224.
This notice is effective as
of April 7, 2003.
