Effective date: April 14, 2003
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.
Alice Hyde Medical Center (the Medical Center) is strongly
committed to protecting the confidentiality and security of
your protected health information. This notice describes our
privacy practices. Specifically, this notice describes: 1)
how we will use or disclose medical information about you;
2) your rights with respect to your protected health information
and how you may exercise your rights; and 3) the obligations
we have regarding the use and disclosure of your protected
health information.
The law requires that we maintain the privacy of your protected
health information, provide you with notice of our legal obligations
and privacy practices with respect to your protected health
information, and follow the terms of the notice that is currently
in effect.
FURTHER INFORMATION ABOUT THIS NOTICE
Privacy Contact: If you have any questions or want further
information about this notice, or anything contained in this
notice, you should contact the individual listed at the end
of this notice.
WHO WILL FOLLOW THIS NOTICE
All individuals who work for the Medical Center in our hospital,
skilled nursing facility, outpatient clinics, and administrative
offices will follow this notice. Examples of these individuals
include employees (including employed physicians), persons
we contract with who are authorized to access your protected
health information, and volunteers that we permit to assist
you.
PROTECTED HEALTH INFORMATION
"Protected health information" is information, including
demographic information, that relates to your past, present
or future physical or mental health or condition; or to the
provision or payment of your health care; and that either identifies
you or reasonably could be used to identify you.
USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION
OR AN OPPORTUNITY TO OBJECT
For Treatment Within the Medical Center. We may use or disclose
your protected health information to individuals within the
Medical Center for the purpose of providing medical treatment
and services to you. For example, we may disclose your protected
health information to other doctors, nurses, technicians, medical
students or other personnel within our Medical Center who are
involved in treating and caring for you.
For Health Care Operations. We may use or disclose your protected
health information during the course of operating the Medical
Center. For example, we may review our patients’ medical
information to ensure that quality treatment or services were
provided to our patients. Also, in conducting training programs,
your medical information may be given to students, trainees,
or other practitioners being supervised to learn or improve
skills. Specific health care operations also include:
Appointment Reminders. We may use and disclose your protected
health information for the purpose of contacting you to remind
you of an appointment you have for treatment or care.
Treatment Alternatives and Other Health-Related Benefits or
Services. We may use and disclose your protected health information
to provide you with information about treatment alternatives
or for the purpose of contacting you to alert you of other
health-related benefits or services that may be of interest
to you.
As Required by Law. We will disclose your protected information
when required to do so by federal, state or local law.
To Qualified Persons. Under New York State law, a health care
provider may disclose your patient information to “qualified
persons” without your authorization. These “qualified
persons” include: the subject of the information (you),
a guardian appointed under the mental hygiene law, a parent
of an infant, a guardian of an infant who has been appointed
by the surrogate court, or an attorney appointed to act on
behalf of the individual or the individual’s estate.
Public Health Activities. Your protected health information
may be disclosed to public health authorities authorized by
law to collect and receive the information. For instance, the
information may be disclosed for the purpose
of: preventing, controlling, or monitoring disease, injury
or disability; reporting birth and death; reporting child abuse
or neglect; reporting adverse reactions to medications or products;
providing notification of product recalls; providing notification
to individuals exposed to a communicable disease or at risk
of contracting and spreading a disease or condition; and evaluating
work-related injuries or illness.
Abuse, Neglect or Domestic Violence. If it is reasonably believed
that you are a victim of abuse, neglect or domestic violence,
we are allowed to disclose your protected health information
to government authorities, such as social or protective service
agencies, that are authorized to receive reports on abuse,
neglect and domestic violence.
Health Oversight Activities. We may disclose protected health
information to agencies authorized by law to conduct health
oversight activities.
Legal Disputes. We may disclose your protected health information
as part of a court or government agency proceeding.
Law Enforcement Officials. We may disclose your protected
health information to law enforcement officials as required
by law.
Coroners and Medical Examiners. Your protected health information
may be disclosed to coroners and medical examiners to identify
the deceased or to determine the cause of death or to conduct
other duties authorized by law.
Funeral Directors. We may disclose your protected health information
to a funeral director as required by law and additionally so
that they may carry out their duties.
Organ and Tissue Donation. We may disclose your protected
health information to organ and tissue Medical Centers for
the purpose of obtaining donations and transplantations.
Prevention of Serious Threat to Health or Safety. We may disclose
your protected health information to prevent serious threat
to the health and safety of a specific person or the general
public. Use and disclosure may only be made if necessary and
to someone reasonably able to prevent or lessen the threat.
Specialized Government Functions:
•
Military Activity and National Security
•
Workers’ Compensation
•
Inmates
Disclosures to the Secretary of the Department of Health and
Human Services. We must make disclosures when required by the
Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements
of the HIPAA regulations.
WHERE YOUR AUTHORIZATION IS NOT REQUIRED BUT YOU HAVE THE
OPPORTUNITY TO OBJECT PRIOR TO THE USE OR DISCLOSURE
Notification. We may disclose your protected health information
to a family member, other relative, close personal friend,
or other person identified by you, who is involved in your
care, or the payment of your care. The information disclosed
must be relevant to the individual’s involvement. We
may also disclose protected health information to notify a
family member, or another person responsible for your care,
of your location, general condition, or death. If you are unable
to agree or object to such uses or disclosures of protected
health information because of an emergency or because of your
incapacity, we may exercise our professional judgment to determine
whether the disclosure is in your best interest.
Directory Use. Your protected health information may be disclosed
to maintain a directory of patients in our facility. Such information
is limited to your name, your location within our facility,
your general condition, and your religious affiliation. The
information contained within this directory may be disclosed
to members of the clergy, or to other individuals who ask for
you by name. If you are unable to agree or object to such disclosure,
we may disclose the information contained within the directory
only if it is consistent with your prior expressed preference,
and if we determine that it is in your best interest based
upon our professional judgment.
USES AND DISCLOSURES WHERE YOUR AUTHORIZATION IS REQUIRED
For all other uses and disclosures of your protected health
information not described above, your authorization is required
prior to such disclosure. Some examples include:
For Treatment Outside the Medical Center. If your protected
health information is shared with those outside the Medical
Center for treatment purposes, your authorization is required
under New York State law. For certain specific conditions (HIV,
mental illness, and genetic information and testing), New York
State law provides heightened protection and we must obtain
written informed consent prior to disclosing information outside
of the Medical Center.
For Payment. Your authorization is required to disclose your
protected health information in order to obtain payment for
the treatment or services provided to you. For example, it
may be necessary to provide your health plan with information
about your condition and the treatment you received in order
to establish the medical necessity for the treatment. Also,
many plans require that certain medical procedures be approved
for payment in advance of providing the treatment or procedure.
You are able to revoke an authorization that was obtained
for the use or disclosure of your protected health information,
in writing, at any time. The authorization cannot be revoked
to the extent: 1) we have already relied and acted upon the
authorization; or 2) the authorization was made as a condition
to obtaining insurance coverage.
YOUR RIGHTS PERTAINING TO YOUR PROTECTED HEALTH INFORMATION
Right to Access. You have the right to inspect and/or to obtain
a copy of the health information pertaining to you. To request
access to your protected health information, please contact
our Privacy Contact, who is listed at the end of this notice.
A reasonable fee may be charged to cover the costs of providing
you with a copy of your protected health information, however,
that fee may not exceed seventy-five cents per page. A charge
will not be assessed for a copy of an original mammogram when
the original is provided. Further, the release of your protected
health information will not be denied solely because of an
inability to pay.
We will try our best to provide your protected health information
to you in the form or format requested by you if such form
or format is readily available. If it is not, the information
will be provided in readable hard copy form or such other agreed
upon form. If you agree in advance, we may provide you with
a summary or explanation of your protected health information.
You must also agree in advance to pay the fee for preparation
of such summary or explanation.
You have the right to timely access to your protected health
information. Generally, your request must be acted upon within
ten (10) days of receipt of the request.
We may deny access to your protected health information in
a limited number of instances. If we deny your request, you
have the right to receive a timely written denial explaining
the reasons for the denial. The written denial will also describe
your right to review the denial and the procedures for filing
a complaint. Your denial will be reviewed, without cost, by
the appropriate Medical Record Access Committee appointed by
the Commissioner of the New York State Department of Health.
Right to Amend. If you believe that health information contained
in your medical and billing records maintained by us is incorrect
or incomplete, you have the right to request that it be amended.
To request an amendment, please write to our Privacy Contact
and include the information you want changed and the reason
for wanting this information changed.
We may deny your request for an amendment if your health information
was not created by us (unless the originator of the health
information is no longer available to act on your request);
is not part of the medical and billing records kept by us;
is accurate and complete; or would not be available to you
for inspection. If we deny your request for amendment, we must
provide you with a written denial explaining the reasons for
the denial. You have the right to submit a written statement
of disagreement. You may also file a complaint. If we prepare
a written rebuttal, you will be provided a copy of the rebuttal.
Right to an Accounting of Disclosures. You have the right
to know who has received your protected health information
other than disclosures made to you, disclosures made for treatment,
payment, or health care operations, or those made pursuant
to an authorization. You may request that we provide you with
a written statement or listing (referred to as an "accounting")
of disclosures of your protected health information that occurred
during the six years prior to your request, provided that such
disclosures were made after April 14, 2003.
The accounting will include: dates of disclosures; name of
entities or persons who received your protected health information;
a brief description of the protected health information disclosed;
and a statement regarding the purpose for the disclosure, or
a copy of your written authorization for the disclosure.
To request an accounting, please write to our Privacy Contact
and include the time frame for which you wish to receive an
accounting. The first accounting within a 12-month period will
be provided free of charge. We may charge a reasonable fee
for additional accountings requested within the same 12-month
period. You will be advised of the charge before the accounting
is prepared in order to provide you with an opportunity to
withdraw or to modify your request. In limited circumstances,
certain disclosures are not included in the accounting. If
you have questions regarding which disclosures are not included,
you may contact the person listed at the end of this Notice
for more information.
Right to Restrict Uses and Disclosure. We understand that
there may be situations in which you do not want your protected
health information used by or disclosed to others. You may
request that the use and disclosure of your protected health
information by us, within the Medical Center, for treatment,
payment or health care operations, be restricted or limited.
We are not required to agree to the restriction or limitation.
If we do agree to the restriction or limitation, we will follow
your wishes except to the extent that use or disclosure may
be necessary to provide you emergency treatment. If we must
use or disclose protected health information in order to provide
emergency treatment, we will request that the disclosed information
not be further used or disclosed.
To request that a restriction or limitation be placed on your
protected health information, please write to our Privacy Contact.
You may also write to this person to terminate a restriction
or limitation. We may terminate a restriction or limitation
by informing you of the termination. A termination will only
be effective for protected health information created or received
after you have been informed of the termination.
Right to Request Confidential Communications. You may request,
in writing, to receive confidential communications regarding
your protected health information by an alternative method
or at an alternative location. For instance, if you wish to
receive confidential communications by e-mail or at another
address, such as at work or at a post office box, you may request
it. We will not ask you to explain your reason for the request
and will accommodate reasonable requests.
To request confidential communications, please write to our
Privacy Contact.
COMPLAINT PROCEDURES
If you believe that your protected health information was
used or disclosed unlawfully, or that any of your rights with
respect to your protected health information were violated,
you may file a complaint with us or with the Secretary of the
U.S. Department of Health and Human Services. If complaining
to us, your complaint should be in writing and sent to our
Privacy Contact. This is the same person you may contact with
questions regarding any of the information contained in this
notice.
PLEASE BE ADVISED THAT NO ADVERSE ACTION WILL BE TAKEN AGAINST
YOU FOR FILING A COMPLAINT.
RIGHT TO CHANGE NOTICE
We reserve the right to change this notice. We also reserve
the right to make the revised or changed notice effective for
medical information we already have about you and for information
we may receive in the future. A current copy of this notice
is always posted in the hospital, the skilled nursing facility
and at each of our clinics, and you may find it on our web
site at http://www.alicehyde.com.
In addition, when we change the notice, we will mail a revised
notice to you (or, you will be given the new notice on your
first service date after the revised notice is effective).
You may always request a copy of our current notice by contacting
our Privacy Contact person.
PRIVACY CONTACT
If you have any questions about this Notice please contact:
Ginger Carriero
Privacy Officer
Alice Hyde Medical Center
133 Park Street
P.O. Box 729
Malone, New York 12953
483-3000 ext. 390
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