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Notice of Privacy Practices

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

This Practice is required by law to maintain the privacy of the protected health information of its patients. “Protected health information” includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. This Notice will provide you with information regarding the privacy practices of this Practice with respect to protected health information. It describes our legal duties to you with respect to protected health information and your rights to access and control your protected health information. This notice applies to all of your health information created and/or maintained at our Practice including information about you that we received from other health care providers or facilities.

We are required, by law, to abide by the terms of our Notice of Privacy Practices. We reserve the right, however, to change our practices and amend our Notice at any time and to make the new provisions effective for all protected health information that we maintain at that time. You will be provided, upon request, with any revised Notice of Privacy Practices. Simply call the office or send a written request to the Privacy Officer listed at the end of this document and request that a revised copy be provided to you.

PERMISSIBLE USES AND DISCLOSURES

We may use or disclose your protected health information for purposes of treatment, payment and health care operations.   For each of these categories of uses and disclosures, we have provided a description and an example below, however, not every particular use or disclosure in every category is listed.

I. Treatment
Your protected health information may be used to render healthcare treatment to you. For example, healthcare providers (i.e. , doctors, nurses, therapists, etc. ) may use your health information to determine the appropriate treatment to be rendered to you. Your protected health information also may be used and disclosed among the healthcare providers who are involved in your care. For example, your doctor may speak with the nursing staff to coordinate and develop a plan of care for you.

II. Payment
Your protected health information may also be used and disclosed to obtain payment for treatment rendered to you. For example, your health insurance plan or other third party payor may be billed for the services you receive. The bill may be created using information from your medical records and may contain information relating to your treatment including, but not limited to: supplies, examinations, lab visits, etc. Your protected health information may also be used and/or disclosed to your health insurance plan or third party payor to determine: eligibility, coverage, benefits and medical necessity. For example, prior to providing health care services, we may need to provide information to your third party payor about your medical condition to determine whether the proposed course of treatment will be covered. We may also disclose your protected information in connection with activities which we may undertake to obtain reimbursement for the health care provided to you, including: billing, collections, claims management, determinations of eligibility and coverage and other utilization review activities.

III. Health Care Operations

Your protected health information may be used or disclosed in connection with the operational activities of our Practice. Such uses and disclosures are necessary for the efficient operation of our Practice so that we may render the highest quality of care to our patients. These activities include, but are not limited to, quality assessment, employee review, training of medical students, and licensing. Your protected health information may also be disclosed to the Practice’s business associates who provide contracted services such as accounting, legal representation, claims processing, accreditation, and consulting. If we disclose your protected health information to a business associate, we will do so subject to an agreement that provides that the information should be kept confidential.

We may also combine and use health information about many of our patients to decide:
(a) what additional services the Practice should offer;
(b) what services are not needed; and
(c) whether certain new treatments are effective.

We may also combine and use the health information we have with health 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 also remove information that identifies you from the health information so others may use it to study health care and health care delivery without learning who the specific patients are.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may also use and disclose your protected health information for marketing and fundraising activities. For example, your name and address may be used to send you a newsletter about our Practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.

We may also disclose information to doctors, nurses, technicians, medical students and others for review and learning purposes.

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.

IV. Uses and/or disclosures pursuant to your written authorization
By law, we must have your written authorization to use or disclose your protected health information for any purpose that is not otherwise set out in this notice. You may revoke your permission at any time, in writing, except to the extent that we have acted in reliance on your permission. As discussed herein, the following uses and disclosures do not require your authorization and will be made as necessary:
(a) to carry out treatment, payment or healthcare operations;
(b) made pursuant to your verbal or written consent; or
(c) made as permitted by law.

V. Uses and/or disclosures without your written authorization
In limited circumstances, we may use or disclose your protected health information without your written authorization, provided that prior to the use or disclosure, you are informed and given the opportunity to agree to, prohibit or restrict the use or disclosure. We may verbally inform you of these disclosures and obtain your agreement or objection verbally. Such uses and disclosures include those: a) made for the Practice directory, b) made to notify your friends and family of your location and/or condition; or c) made to your family members, personal representative, or others involved in your care.

OTHER USES AND DISCLOSURES

In addition to using and disclosing your information for treatment, payment and health care operations, we may use your protected health information in the following ways:

VI. PUBLIC POLICY DISCLOSURES

As required by law
We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures of which we are aware.

For public health activities
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. We may also disclose your protected information to public health authorities to: report births and deaths or for activities related to quality, safety or effectiveness of the Food and Drug Administration (FDA) FDA-regulated products or services and to report reactions to medications or problems with products, to persons subject to jurisdiction of the FDA.

Victims of abuse, neglect or domestic violence
We may disclose your protected health information, if we believe that you have been a victim of abuse, neglect or domestic violence, to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Law enforcement purposes
We may also disclose your protected health information, so long as applicable legal requirements are met, for law enforcement purposes. We may disclose your protected health information:
(a) in response to a court order, subpoena, warrant, summons or similar process;
(b) to identify or locate a suspect, fugitive, material witness, or missing person;
(c) as it pertains to the victim of a crime under certain limited circumstances;
(d) as it pertains to a death we believe may be the result of criminal conduct;
(e) as it pertains to criminal conduct on our premises; and
(f) in emergency circumstances, to:
i. report a crime;
ii. the location of the crime or the victims; or
iii. the identity, description or location of the person who committed the crime.

To family, friends and others involved in your care
With your consent, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information, as necessary, if we receive the consent of your legal representative or if we determine, in our professional judgment, that it is in your best interest. Additionally, we may use or disclose your protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.

Coroners, medical examiners and funeral directors
We may disclose your protected health information to a coroner or medical examiner for identification purposes; determining cause of death; or for the coroner or medical examiner to perform duties authorized by law. We may also disclose your protected health information, with consent, to a funeral director as necessary to carry out its duties.

Serious and imminent threats
We may disclose your protected health information if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Cadaveric organs, eye or tissue donation purposes
If you are an organ or tissue donor, we may disclose your protected health information for cadaveric organ, eye or tissue donation purposes.

Research
We may disclose your protected health information to researchers when their research has been approved by an Institutional Review Board (IRB) that has reviewed the research proposal, and established protocols to ensure the privacy of your protected health information. When required, we will obtain a written authorization from you, or an appropriate waiver from an IRB or Privacy Board, prior to disclosing your health information for research.

Disaster relief efforts
We may disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts.

National security and intelligence
We may disclose your protected health information to authorized federal officials, or others legally authorized, to conduct national security and intelligence activities.

Workers compensation
Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs that provide benefits for work related injuries or illnesses.

Appointment reminders/Treatment alternatives
We may use your health information to remind you of appointments or to give you information about treatment alternatives or other health related benefits and services that may be of interest to you. If you do not wish us to do this, please notify our Privacy Officer in writing.

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 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 efforts have been made to tell you about the request or to obtain an order protecting the information you requested.

Fundraising
We may contact you to raise funds for the Practice. If you do not wish to receive any further fundraising communications, you must follow the opt out procedures contained in the communication.

Marketing
In the course of your face to face treatment or care, you may on occasion receive products or services of nominal value. No other communications about products or services which you may be encouraged to purchase or use, will be made without your written authorization, unless the service or product is provided by this Practice or our network of providers.

YOUR RIGHTS

VII. Restrictions
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information to carry out treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to a restriction that you may request. If the Practice believes it is in your best interest to permit uses and disclosures of your protected health information, your protected health information will not be restricted. However, if the Practice does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, you may request a restriction by forwarding a written restriction request to the Privacy Officer at the address listed below.

VIII. Confidential communications
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests; however, we may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make requests for such communications in writing to our Privacy Officer at the address below.

IX. Right to inspect and copy protected health information
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is maintained by the Practice. Under applicable federal law, however, you may not inspect or copy the following records:
(a) psychotherapy notes;
(b) information compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding;
(c) protected health information that is subject to laws that prohibit access to protected health
information.
(d) Protected health information that was created or obtained by the Practice in the course of research that includes treatment may be temporarily suspended for as long as the research is in progress, provided that you have agreed to the denial of access when consenting to participate in the research, and have been informed that the right of access will be reinstated upon completion of the research;
(e) Records that are subject to the Privacy Act;
(f) Protected health information obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

Depending on the circumstances, a decision to deny access to certain information may be made. In some circumstances, you have a right to have this decision reviewed by a licensed health care professional designated by the Practice to be the “Reviewing Official”. Please contact our Privacy Officer if you have questions about access to your medical record.

X. Right to amend protected health information
You may have the right to amend your protected health information. This means you may request an amendment of your protected health information. We may, however, deny your request if the information:  

  1. was not created by us, and the originator of protected health information is available to act on the requested amendment;
  2. is not part of your medical or billing records or other records used to make decisions about you;
  3. is not available for inspection as set forth above; or
  4. is accurate and complete.

Your request for amendment must be made in writing and include a reason to support the requested amendment. We are not required to act on a request that does not meet these requirements.

If request for amendment is denied, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your health record.

XI. Right to receive an accounting of disclosures
You have the right to receive an accounting of certain disclosures of your protected health information made by us that we are aware of, for up to six prior years prior to your request, except for disclosures made:

(a) to carry out treatment, payment and health care operations as provided above;
(b) incident to a use or disclosure otherwise permitted or required by applicable law;
(c) pursuant to your written authorization or consent;
(d) to you about yourself;
(e) for national security or intelligence purposes as provided by law;
(f) to correctional institutions or law enforcement officials as provided by law;
(g) as part of a limited data set as provided by law; or
(h) that occurred prior to April 14, 2003.

The right to receive this information is subject to certain exceptions, restrictions and limitations.

XII. Copy of this Notice
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

XIII. Practice’s obligation
This Practice is required by law to maintain the privacy of protected health information and to provide patients with notice of its legal duties and privacy practices with respect to protected health information.

XIV. Terms of Notice in effect
We will abide by the terms of this Notice. If any future revisions are made to this Notice, as required or authorized by law, we will abide the terms of the then current Notice in effect.

XV. Revisions to Notice
We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. We will post a copy of the most current Notice in our offices and on our website (if active) and we will provide patients with a copy of the then current Notice upon request, including any revisions.

XVI. Complaints
If you believe that your privacy rights relating to your health information have been violated, you may file a complaint with Island Medical House Doctor, P.C. by sending a written complaint to the Privacy officer at the address below, or by  sending a written complaint to the Secretary of the United States Department of Health and Human Services at: Office for Civil Rights, U.S. Department of Health and Human Services,  26 Federal Plaza, Room 3312, New York, NY, 10278; Voice Phone (212) 264-3313; Fax (212) 264-3039; TDD (212) 264-2355. The complaint must name the Practice complained about and must describe the acts or omissions believed to be a violation of the privacy of your health information. The complaint must be filed within 180 days of when you knew or should have known that the act or omission that you are complaining about occurred. (This time limit may be waived by the Secretary for good cause. ) The Secretary may investigate your complaint including the circumstances regarding any alleged acts or omissions.

You will not be retaliated against for filing a complaint.

XVII. Effective date
The first page of this Notice, or any revisions thereof, will contain the effective date of the Notice or Revision.

If you have any questions or complaints regarding this notice or the confidentiality of your health information, please contact:

Island Medical House Doctor, P.C. ’s Privacy Officer at 631-514-7600 or by writing to:

Island Medical House Doctor, P.C.
88 Arkay Drive
Hauppauge, NY 11901
Attn: Privacy Officer