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.
Understanding Your Health Record / Information
Each time you visit a practitioner, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment
• Means of communication among the health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided
• Tool in educating health professionals
• Source of data for medical research
• Source of information for public health officials who oversee the delivery of health care in the United States
• Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
This practitioner is required to:
• Maintain the privacy of your health information
• Provide you with a notice as to our legal duties and privacy practices with respect to
information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by
alternative means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail you a revised notice.
We will not use or disclose your health information without your authorization, except as described in this notice.
We reserve the right to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
How We Will Use or Disclose Your Health Information
Treatment:We will use your health information for treatment. For example: information obtained by us will be recorded in your record and used to determine the course of treatment that should work best for you. We will record the actions we take and our observations. In that way, we will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from treatment.
Payment:We will use your health information for payment. Example: a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on, or accompanying, the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
Health Care Operations:We will use your health information for regular health operations. Example: we may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
Business Associates:There are some services provided in our organization through contacts with business associates. Examples include our accountants, consultants and attorneys. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information.
Notification:We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answering machine.
Communication with Family:Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Research:We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Marketing:We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Workers Compensation:We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health:As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional Institution:Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement:We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Reports:Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
Your Health Information Rights
Although your health record is the physical property of the practitioner, the information in your health record belongs to you. You have the following rights:
~ You may request that we not use or disclose your health information for a particular reason related to treatment, payment, our general health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept it or to abide by it. We will abide by your requests with regard to the disclosure of your clinical and personal records to anyone outside of the practice, except in an emergency, if you are being transferred to practitioner, or if the disclosure is required by law. 42 C.F.R. ξ 483.10(e) provides that a practitioner must abide by a patient’s right to refuse the release of his/her personal or clinical records to any individual outside of the practice unless the release is necessary because the patient is being transferred to another health care practitioner or it is required by law.
~ You may request an accounting of disclosures of protected health information as provided by ξ 164.528
~ If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you such information by alternative means or at alternative locations. Such a request must be made in writing. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R. ξ 164.522(b).
~ You may request to inspect and/or obtain copies of health information about you, which will be provided to you within time frames established by law. You may make such requests orally or in writing; however, in order to better respond to your request we ask that you make such requests in writing on our standard form. If you request to have copies made, we will charge you a reasonable fee. For more information about this right, see 45 C.F.R. ξ 164.524.
~ If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by us to make such requests. For more information about this right, see 45 C.F.R. ξ 164.526.
You have the right to obtain a paper copy of our Notice of Information Practices upon request.
You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing.
For More Information or to Report a Problem
If you have questions or would like additional information, you may contact us at:
If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by us. The complaint form, when completed, should be returned to us. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.
Effective Date: April 1, 2003
Yehuda LiebermanLCSW-R, QCSW, DCSW1438 East 26th Street 1011 Nameoke St
Brooklyn, NY 11210 Far Rockaway, NY 11691 Entrance on Cornaga Ave