I acknowledge that I have received the attached 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 Notice of Privacy is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your “protected health information” means any of your written and oral health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition; the provision of health care related to your condition, or the payment for the health care provided to you.
I. Uses and Disclosures of Protected Health Information Without Your AuthorizationWe may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Disclosures of your protected health information for the purposes described in this Notice may be made in writing, orally, by facsimile, or electronically. You will be asked to sign a general consent at your first visit to CNY Family Care, LLP, allowing us to use and disclose your health information for the purposes outlined below:
A. Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose protected health information to other physicians who may be treating you or consulting with your physician with respect to your care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider.
B. Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurer to get approval for the treatment that we recommend. For example, if a hospital admission is recommended, we may need to disclose information to your health insurer to get prior approval for the hospitalization. We may also disclose protected health information to your insurance company to determine whether you are eligible for benefits or whether a particular service iscovered under your health plan. In order to get payment for your services, we may also need to disclose your protected health information to your insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities.
C. Operations. We may use or disclose your protected health information, as necessary, for our own health care operations in order to facilitate the function of the provider and to provide quality care to all patients. Health care operations include such activities as:
In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.
II. Uses and Disclosures Beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:
A. When Legally Required. We will disclose your protected health information when we are required to do so by any Federal, State or local law.
B. When There Are Risks To Public Health. We may disclose your protected health information for the following public activities and purposes:
C. To Report Abuse, Neglect or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
D. To Conduct Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.
E. In Connection With Judicial And Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena in some circumstances.
F. For Law Enforcement Purposes. We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:
G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ eye or tissue donation purposes.
H. For Research Purposes. We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board or privacy board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.
I. In the Event of a Serious Threat To Health or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or to the health and safety of the public.
J. For Specified Government Functions. In certain circumstances, the Federal regulations authorize us to use or disclose your protected health information to facilitate specified government functions relating to military and veteran activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
K. For Workers’ Compensation. We may release your health information to comply with workers’ compensation laws or similar programs.
III. Uses and Disclosures Permitted Without Authorization But With Opportunity to ObjectWe may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.
You may object to these disclosures. If you do not object to these disclosures, or we can infer from the circumstances that you do not object, or we determine, in the exercise of our professional judgment that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described.
IV. Uses and Disclosures Which You AuthorizeOther than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time, except to the extent we have taken action in reliance upon the authorization.
The following uses and disclosures are examples of disclosures that we will make only with your written authorization:
V. Your RightsYou have the following rights regarding your health information:
A. The right to inspect and copy your protected health information. With some limited exceptions, you may inspect and obtain a copy of your protected health information that is contained for as long as we maintain the protected health information.
Under Federal and state law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.
We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person. Or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.
To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last pages of this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.
Please contact our Privacy Officer if you have questions about access to your medical record.
B. The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information 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.
If you have paid for the services we provided in full out of pocket, and you request that we do not disclose your health information related solely to those services to a health plan, we are required to accommodate your request, except where we are required by law to make a disclosure. Otherwise, we are not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If we do 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. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.
C. The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may 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 require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.
D. The right to have your physician amend your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.
E. The right to receive an accounting. You have the right to request an accounting of certain disclosures of your protected health information made by us. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost based fee.
F. The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this Notice, even if you have already received a copy of the Notice or have agreed to accept this Notice electronically.
G. Right to Notice of Breach. We will notify you of any breach of your unsecured health information, unless there is a demonstration, based on a risk assessment, that there is a low probability that your health information has been compromised. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what can be done to lessen any harm.
VI. Our DutiesWe are required by law to maintain the privacy of your health information and to provide you with this Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information created or received prior to and after the revision. If we change our Notice, we will provide a copy of the revised Notice upon request, and post a copy of the new Notice in our service delivery area.
VII. ComplaintsYou have the right to express complaints to us and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to us by contacting our Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
VIII. Contact PersonOur contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer, Melissa Imhoff. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. Complaints against us can be mailed to the Privacy Officer or by sending it to:
CNY Family Care, LLP4939 Brittonfield ParkwayEast Syracuse, NY 13057ATTN: Melissa Imhoff, Privacy Officer
IX. Privacy OfficerOur Privacy Officer can be reached by telephone at 315-463-1600 or by mail at the following:
X. Effective Date This Notice is effective on September 25, 2015.