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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.
 

Federal Law (the Health Insurance Portability and Accountability Act (HIPAA)) requires that health care providers inform patients of their rights regarding how the provider 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. This Privacy Notice describes our privacy practices that relate to your protected health information. It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and oral health information about you, 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.

Your Health Record and Protected Health Information
Each time you receive medical care from our practice, a record of your visit is created. This record typically includes, but is not limited to, information such as your name, age, address, a brief medical history, symptoms, any radiology test results, the treatment provided to you, treatment plans devised for your care, and notes on follow-up care to be performed. How your health care information may be used and what controls you may exercise over the use of your healthcare information is described in this Privacy Notice.
 

Uses and Disclosures of Protected Health Information
Our Practice may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the practice has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.
 

Treatment: We may 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 providers, nurses, technicians, radiology personnel, other practice staff involved in your care and/or a third party for treatment purposes. We may disclose protected health information to physicians who may be treating you or consulting with the practice with respect to your care. In some cases, we may also disclose your protected health information to people outside the facility who may be involved in your medical care while you are in the practice or after you leave the practice, such as other physicians, health care workers, family members, clergy or others we use to provide services that are part of your care.

 

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 insurance company to get approval for the procedure that we have scheduled. We may disclose protected health information to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the services we provide to you, we may also need to disclose your protected health information to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review.

 

Operation: We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of the Facility and to provide quality care to all patients. Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities.
 

In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

 

Other uses and disclosures for health care operations may include:
 

	Care management
	Protocol Development
	Training, accreditation, certification, licensing, credentialing or other related activities
	Activities related to improving health care or reducing health care costs
	Underwriting and other insurance related activities
	Medical review and auditing
	Internal grievance resolution

Appointment Reminders: We may use or disclose your protected health information to contact you, a family member or friend involved in your health care as authorized by you as a reminder that you have an appointment for treatment or medical care at our facility. We may also leave a message on your answering machine / voicemail system unless you tell us not to.

 

Treatment Alternatives: We may use or disclose your protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

 

Health Related Benefits and Services: We may use or disclose your protected health information to tell you about health related benefits or services that may be of interest to you.

 

Individuals Involved in Your Care or Payment of Your Care: We may use or disclose your protected health information to a friend or family member who is involved in your medical care. We may also give information to someone assisting you in the payment for your care. We may also tell your family or friends that you are in the facility at the time of your care, or that information may be communicated to an entity assisting in a disaster relief effort in order to communicate your condition status and location to your family. If you want any of this information restricted you must communicate that to us using the appropriate procedure.

 

To Avert a Serious Threat to Health or Safety: We may use and disclose health information for the following public activities and purposes:
 

	To prevent, control, or report disease, injury or disability as permitted by law.
	To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
	To report to an employer information about an individual who is a member of the workforce as legally permitted or required.

To Conduct Health Oversight Activity: 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 under this authority 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.

 

In Connection With Judicial and Administrative Proceeding: 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. In certain circumstances, we may disclose your protected health information in response to a subpoena to the extent authorized by state law if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.

 

For Law Enforcement Purposes: We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:
 

	As required by law for reporting of certain types of wounds or other physical injuries.
	Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
	For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
	Under certain limited circumstances, when you are the victim of a crime.
	To a law enforcement official if the facility has a suspicion that your health condition was the result of criminal conduct.
	In an emergency to report a crime.

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.

 

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.

 

For Specified Government Functions: In certain circumstances, federal regulations authorize the facility to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

 

For Worker's Compensation: The facility may release your health information to comply with worker's compensation laws or similar programs.

 

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.

 

Uses and Disclosures which you Authorize:

Other 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 that we have taken action in reliance upon the authorization.

 

Your Rights

Although your health record is the physical property of the healthcare practitioner or Facility that compiled it, the information belongs to you. You have the following rights regarding your health information:

 

Right to Inspect and copy your protected health information: You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the Facility uses for making decisions about you.
 

Under federal 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 first page of this Privacy 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.
 

Right to Request amendments to your protected health information: If you feel the health information we have in your record is incorrect or incomplete, you may request an amendment of the information 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. In addition, we may deny your request if you ask us to amend information that:

 

	Was not created by this Facility, unless the person or entity that created the information is no longer available to make the amendment;
	Is not part of the health information kept by our for the Facility;
	Is not part of the information which you would be permitted to inspect and copy; or
	Is accurate and complete.

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.
 

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 Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply. For example, you could ask that certain people not be told of certain information. The facility is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the facility 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. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.
 

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.
 

Right to Receive an accounting: You have the right to request an accounting of certain disclosures of your protected health information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. 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.

 

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.

 

Our Responsibilities

The facility is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our duties and privacy practices. We are required to:

 

	Keep your health information private and only disclose it when required to do so by law;
	Explain our legal duties and privacy practices in connection with your health records;
	Obey the rules found in this notice;
	Inform you when we are unable to agree to a requested restriction that you have given us;
	Accommodate your reasonable request for an alternative means of delivery or destination when sending your health information.

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 future protected health information that we maintain. If the facility changes its Notice, we will provide a copy of the revised Notice by sending a copy of the revised Notice via regular mail or through in-person contact.
 

Complaints

You have the right to express complaints to the Facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the Facitlity's Privacy Officer verbally or in writing, using the contact information provided on the first page of this Privacy Notice. We encourage you to express any concerns you may have regarding the privacy of your information.
 

HIPAA Officer
Marcia Stahl
2365 Boston Post Road
Larchmont, New York, 10538
914-833-9670