I. WITH YOUR CONSENT WE MAY USE AND DISCLOSE YOUR
PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT
AND HEALTH CARE OPERATIONS
You will be asked to sign a Consent allowing us to
use and disclose your Protected Health Information to
others to provide you with treatment, obtain payment
for our services, and run our health care operations.
Here are examples of how we may use and disclose your
For Treatment. Our staff and affiliated health
care professionals may review and record information
in your record about your treatment and care. We will
use and disclose this health information to health care
professionals in order to treat and care for you. For
example, a nurse may consult with another nurse located
at another location to determine how to best treat you.
For Payment. Our agency may use and disclose
your Protected Health Information to others in order
for the agency to bill for your health care services
and receive payment. For example, we may include your
health information in our claim to Blue Cross/Blue Shield,
Medicare or Medicaid in order to receive payment for
services provided to you. We may also disclose your
health information to other health care providers so
that they can receive payment for your services.
For Health Care Operations. We may use and
disclose your Protected Health Information to others
for our agency's business operations. For example, we
may use Protected Health Information to evaluate our
agency's services, including the performance of our
staff, and to educate our staff.
II. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH
INFORMATION FOR OTHER SPECIFIC PURPOSES
Business Associates. We may share your Protected
Health Information with our vendors and agents who help
us with obtaining payment or carrying out our business
functions. For example, we may give your health information
to a billing company to assist us with our billing for
services, or to a law firm or an accounting firm that
assists us in complying with the law and or improving
Family and Friends Involved in Your Care. Unless
you object, we may disclose your Protected Health information
to a family member or close personal friend, including
clergy, who is involved in your care or payment for
Disaster Relief. We may disclose your Protected
Health Information to an organization assisting in a
disaster relief effort.
Public Health Activities. We may disclose your
Protected Health Information for public health activities
including the reporting of disease, injury, vital events,
and the conduct of public health surveillance, investigation
and/or intervention. We may also disclose your information
to notify a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or
spreading a disease or condition if a law permits us
to do so.
Health Oversight Activities. We may disclose
your Protected Health Information to health oversight
agencies authorized by law to conduct audits, investigations,
inspections and licensure actions or other legal proceedings.
These agencies provide oversight for the Medicare and
Medicaid programs, among others.
Reporting Victims of Abuse, Neglect or Domestic
Violence. If we have reason to believe that you
have been a victim of abuse, neglect or domestic violence,
we may use and disclose your Protected Health Information
to notify a government authority if required or authorized
by law, or if you agree to the report.
Law Enforcement. We may disclose your Protected
Health information for certain law enforcement purposes
or other specialized governmental functions.
Judicial and Administrative Proceedings. We
may disclose your Protected Health Information in the
course of certain judicial or administrative proceedings.
Research. In general, we will request that
you sign a written authorization before using your Protected
Health Information or disclosing it to others for research
purposes. However, we may use or disclose your health
information without your written authorization for research
purposes provided that the research has been reviewed
and approved by a special Privacy Board or Institutional
Coroners, Medical Examiners, Funeral Directors,
Organ Procurement Organizations. We may release
your health information to a coroner, medical examiners,
and funeral director or, if you are an organ donor,
to an organization involved in the donation of organs
To Avert a Serious Threat to Health or Safety.
We may use and disclose your Protected Health Information
when necessary to prevent a serious threat to your health
or safety or the health or safety of the public or another
person. However, any disclosure would be made only to
someone able to help prevent the threat.
Military and Veterans. If you are a member
of the armed forces, we may use and disclose your Protected
Health Information as required by military command authorities.
We may also use and disclose Protected Health Information
about foreign military personnel as required by the
appropriate foreign military authority.
Workers' Compensation. We may use or disclose
your Protected Health Information to comply with laws
relating to workers' compensation or similar programs.
National Security and Intelligence Activities;
Protective Services. We may disclose health information
to authorized federal officials who are conducting national
security and intelligence activities or as needed to
provide protection to the President of the United States,
or other important officials.
As Required By Law. We will disclose your Protected
Health Information when required by law to do so.
III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES
OF YOUR PROTECTED HEALTH INFORMATION
We will use and disclose your Protected Health Information
other than as described in this Notice or required by
law only with your written Authorization. You may revoke
your Authorization to use or disclose Protected Health
Information in writing, at any time. To revoke your
Authorization, contact the Medical Records/Health Information
Management (HIM) staff. If you revoke your Authorization,
we will no longer use or disclose your Protected Health
Information for the purposes covered by the Authorization,
except where we have already relied on the Authorization.
IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights with respect to your health
information. If you wish to exercise any of these rights,
you should make your request to the Medical Records/HIM
Right of Access to Protected Health Information.
You have the right to request, either orally or in writing,
to inspect and obtain a copy of your Protected Health
Information, subject to some limited exceptions. We
must allow you to inspect your records within 10 days
of your request. If you request copies of the records,
we must provide you with copies within a reasonable
time but not more than 30 days if the records are maintained
onsite or 60 days if the records are maintained off-site.
We may charge a reasonable fee for our costs in copying
and mailing your requested information.
In certain limited circumstances, we may deny your
request to inspect or receive copies. If we deny access
to your Protected Health Information, we will provide
you with a summary of the information, and you have
a right to request review of the denial. We will provide
you with information on how to request a review of our
denial and how to file a complaint with us or the Secretary
of the Department of Health and Human Services.
Right to Request Restrictions. You have the
right to request restrictions on the way we use and
disclose your Protected Health Information for our treatment,
payment or health care operations. You also have the
right to restrict your Protected Health Information
that we disclose to a family member, friend or other
person who is involved in your care or the payment for
We are not required to agree to your requested restriction,
and in some cases, the law may not permit us to accept
your restriction. However, if we do agree to accept
your restriction, we will comply with your restriction
except if you are being transferred to another health
care institution, the release of records is required
by law, or the release of information is needed to provide
you emergency treatment.
Right to an Accounting of Disclosures. You have
the right to request an "accounting" of our
disclosures of your Protected Health Information. This
is a listing of certain disclosures of your Protected
Health Information made by the agency or by others on
our behalf, but does not include disclosures made for
treatment, payment and health care operations or certain
You must submit a request in writing, stating a time
period beginning after April 13, 2003 that is within
six years from the date of your request. For example,
you may request a list of disclosures the agency made
between May 1, 2003 and May 1, 2004. You are entitled
to one free accounting within one 12-month period. For
additional requests, we may charge you our costs.
We will usually respond to your request within 60 days.
Occasionally, we may need additional time to prepare
the accounting. If so, we will notify you of our delay,
the reason for the delay, and the date when you can
expect the accounting.
Right to Request Amendment. If you think that
your Protected Health Information is not accurate or
complete, you have the right to request that the agency
amend such information for as long as the information
is kept in our records. Your request must be in writing
and state the reason for the requested amendment. We
will usually respond within 60 days, but will notify
you within 60 days if we need additional time to respond,
the reason for the delay and when you can expect our
response. We may deny your request for amendment, and
if we do so, we will give you a written denial including
the reasons for the denial and an explanation of your
right to submit a written statement disagreeing with
Right to a Paper Copy of This Notice. You have
the right to obtain a paper copy of this Notice, even
if you have agreed to receive this Notice electronically.
You may request a copy of this Notice at any time.
Right to Request Confidential Communications.
You have the right to request that we communicate with
you concerning personal health matters in a certain
manner or at a certain location. For example, you can
request that we speak to you only at a private location
in your home. We will accommodate your reasonable requests.
If you believe that your privacy rights have been violated,
you may file a complaint in writing with us or with
the Office of Civil Rights in the U.S. Department of
Health and Human Services. To file a complaint with
the agency, contact Bader Reynolds (315) 315 797-7050.
No one will retaliate or take action against you for
filing a complaint.
VI. CHANGES TO THIS NOTICE
We will promptly revise and distribute this Notice
whenever there is a material change to the uses or disclosures,
your individual rights, our legal duties, or other privacy
practices stated in this Notice. We reserve the right
to change this Notice and to make the revised or new
Notice provisions effective for all Protected Health
Information already received and maintained by the agency
as well as for all Protected Health Information we receive
in the future. We will post a copy of the current Notice
in the agency. In addition, we will provide a copy of
the revised Notice to all patients by mailing or hand-delivering
a hard copy to them or their personal representatives.
VII. FOR FURTHER INFORMATION
If you have any questions about this Notice or would
like further information concerning your privacy rights,
please contact Bader Reynolds (315) 797-7050.