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NOTICE REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION
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 regulations developed under the Health Insurance Portability
and Accountability Act (HIPAA) require that the practice provide
you with this Notice Regarding Privacy of Personal Health Information.
The Notice describes (1) how the practice may use and disclose your
protected health information, (2) your rights to access
and control your protected health information in certain circumstances,
and (3) the practices’ duties and contact information.
I. Protected Health Information (PHI)
"Protected health information" (PHI) is health information
created or received by your health care provider that contains information
that may be used to identify you, such as demographic data. It includes
written or oral health information that relates to your past, present
or future physical or mental health; the provision of health care
to you; and your past, present, or future payment for health care.
II. The Use and Disclosure of Protected Health Information in Treatment,
Payment, and Health Care Operations
Your PHI may be used and disclosed by the practice in the course
of providing treatment, obtaining payment for treatment, and conducting
health care operations. Any disclosures may be made in writing,
electronically, by facsimile, or orally. The practice may also use
or disclose your PHI in other circumstances if you authorize the
use or disclosure, or if state law or the HIPAA privacy regulations
authorize the use or disclosure.
Treatment. The practice may use and disclose your PHI in the course
of providing or managing your health care as well as any related
services. For the purpose of treatment, the practice may coordinate
your health care with a third party. For example, the practice may
disclose your PHI to a pharmacy to fulfill a prescription for asthma
medication, to an X-ray facility to order an X-ray, or to another
physician who is administering your allergy shots which we prepared.
In addition, the practice may disclose PHI to other physicians or
health care providers for treatment activities of those other providers.
Payment. When needed, the practice will use or disclose your PHI
to obtain payment for its services. Such uses or disclosures may
include disclosures to your health insurer to get approval for a
recommended treatment or to determine whether you are eligible for
benefits or whether a particular service is covered under your health
plan. When obtaining payment for your health care, the practice
may also disclose your PHI to your insurance company to demonstrate
the medical necessity of the care or for utilization review when
required to do so by your insurance company. Finally, the practice
may also disclose your PHI to another provider where that provider
is involved in your care and requires the information to obtain
payment.
Operations. The practice may use or disclose your PHI when needed
for the practice’s health care operations for the purposes
of management or administration of the practice and of offering
quality health care services. Health care operations may include:
(1) quality evaluations and improvement activities; (2) employee
review activities and training programs; (3) accreditation, certification,
licensing, or credentialing activities; (4) reviews and audits such
as compliance reviews, medical reviews, legal services, and maintaining
compliance programs; and (5) business management and general administrative
activities. For instance, the practice may use, as needed, protected
health information of patients to review their treatment course
when making quality assessments regarding allergy care or treatment.
In addition, the practice may disclose your PHI to another provider
or health plan for their health care operations.
Other Uses and Disclosures. As part of treatment, payment, and
healthcare operations, the practice may also use or disclose your
PHI to: (1) remind you of an appointment including the leaving of
appointment reminder information on your telephone answering machine,
US mail or by email; (2) inform you of potential treatment alternatives
or options; or (3) inform you of health-related benefits or services
that may be of interest to you.
II. Additional Uses and Disclosures Permitted Without Authorization
or An Opportunity to Object
In addition to treatment, payment, and health care operations,
the practice may use or disclose your PHI without your permission
or authorization in certain circumstances, including:
When Legally Required. The practice will comply with any Federal,
state or local law that requires it to disclose your protected health
information.
When There Are Risks to Public Health. The practice may disclose
your PHI for public health purposes, including to, as permitted
or required by law:
(1) Prevent, control, or report disease, injury, or disability;
(2) Report vital events such as birth or death;
(3) Conduct public health surveillance, investigations, and interventions;
(4) Collect or report adverse events and product defects, track
FDA regulated products, enable product recalls, repairs, or replacements,
and conduct post marketing surveillance;
(5) Notify a person who has been exposed to a communicable disease
or who may be at risk of contracting or spreading a disease; and
(6) Report to an employer information about an individual who is
a member of the workforce.
To Report Abuse, Neglect Or Domestic Violence. As required or authorized
by law or with the patient’s agreement, the practice may inform
government authorities if it is believed that a patient is the victim
of abuse, neglect or domestic violence.
To Conduct Health Oversight Activities. The practice may disclose
your PHI to a health oversight agency for use in (1) audits; (2)
civil, administrative, or criminal investigations, proceedings or
actions; (3) inspections; (4) licensure or disciplinary actions;
or (5) other necessary oversight activities as permitted by law.
However, if you are the subject of an investigation, the practice
will not disclose PHI that is not directly related to your receipt
of health care or public benefits.
For Judicial And Administrative Proceedings. The practice may disclose
your PHI for any judicial or administrative proceeding if the disclosure
is expressly authorized by an order of a court or administrative
tribunal as expressly authorized by such order or a signed authorization
is provided.
For Law Enforcement Purposes. The practice may disclose your PHI
to a law enforcement official for law enforcement purposes when:
(1) Required by law to report of certain types of physical injuries;
(2) Required by court order, court-ordered warrant, subpoena, summons
or similar process;
(3) Needed to identify or locate a suspect, fugitive, material
witness or missing person;
(4) Needed to report a crime in an emergency situation.
(5) You are the victim of a crime in specific limited instances;
and
(6) Your death is suspected by the practice to be the result of
criminal conduct.
To Coroners, Funeral Directors, and for Organ Donation. The practice
may disclose PHI to a coroner or medical examiner for the purpose
of (1) identification, (2) determination of cause of death, or (3)
performance of the coroner or medical examiner’s other duties
as authorized by law. In addition, as permitted by law, the practice
may disclose PHI, including when death is reasonably anticipated,
to a funeral director to enable the funeral director to carry out
his or her duties. PHI may also be used and disclosed for the purpose
of cadaveric organ, eye or tissue donation.
To Prevent or Diminish A Serious and Imminent Threat To Health
Or Safety. If in good faith the practice believes that use or disclosure
of your PHI is necessary to prevent or diminish a serious and imminent
threat to your health or safety or to the health and safety of the
public, the practice may use or disclose your PHI as permitted under
law and consistent with ethical standards of conduct.
For Specified Government Functions. As authorized by the HIPAA
privacy regulations, the practice may use or disclose your PHI 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 practice may disclose your PHI to
comply with worker's compensation laws or similar programs.
III. Uses and Disclosures Permitted With An Opportunity to Object
Subject to your objection, the practice may disclose your PHI (1)
to a family member or close personal friend if the disclosure is
directly relevant to the person's involvement in your care or payment
related to your care; or (2) when attempting to locate or notify
family members or others involved in your care to inform them of
your location, condition or death. The practice will inform you
orally or in writing of such uses and disclosures of your PHI as
well as provide you with an opportunity to object in advance. Your
agreement or objection to the uses and disclosures can be oral or
in writing. If you do not object to these disclosures, the practice
is able to infer from the circumstances that you do not object,
or the practice determines, in its professional judgment, that it
is in your best interests for the practice to disclose information
that is directly relevant to the person's involvement with your
care, then the practice may disclose PHI. If you are incapacitated
or in an emergency situation, the practice may exercise its professional
judgment to determine if the disclosure is in your best interests
and, if such a determination is made, may only disclose information
directly relevant to your health care.
IV. Uses and Disclosures Authorized by You
Other than the circumstances described above, the practice will
not disclose your health information unless you provide written
authorization. You may revoke your authorization in writing at any
time except to the extent that the practice has taken action in
reliance upon the authorization.
V. Your Rights
You have certain rights regarding your PHI under the HIPAA privacy
regulations. These rights include:
The right to inspect and copy your protected health information.
For as long as the practice holds your PHI, you may inspect and
obtain a copy of such information included in a designated record
set. A "designated record set" contains medical and billing
records as well as any other records that your physician and the
practice uses to make decisions regarding the services provided
to you. The practice may deny your request to inspect or copy your
protected health information if the practice determines in its professional
judgment 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 referred to in the information.
You have the right to request a review of this decision.
In addition, you may not inspect or copy certain records by law,
including: (1) information compiled in reasonable anticipation of,
or for use in, a civil, criminal, or administrative action or proceeding;
and (2) PHI that is subject to a law that prohibits access to protected
health information. You may have the right to have a decision to
deny access reviewed in some situations. You must submit a written
request to the practice’s Privacy Officer to inspect and copy
your health information. The practice may charge you a fee for the
costs of copying,
mailing, or other costs incurred by the practice in complying with
your request. Please contact our Privacy Officer if you have questions
about access to your medical record at the number given on the last
pages of this Notice.
The right to request a restriction on uses and disclosures of your
protected health information. You may request that the practice
not use or disclose specific sections of your PHI for the purposes
of treatment, payment, or health care operations. Additionally,
you may request that the practice 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. In your request,
you must specify the scope of restriction requested as well as the
individuals for which you want the restriction to apply. Your request
should be directed to the practice’s Privacy Officer. The practice
may choose to deny your request for a restriction, in which case
the practice will notify you of its decision. Once the practice
agrees to the requested restriction, the practice may not violate
that restriction unless use or disclosure of the relevant information
is needed to provide emergency treatment. The practice may terminate
the agreement to a restriction in some instances.
The right to request to receive confidential communications from
the practice by alternative means or at an alternative location.
You have the right to request that the practice communicates with
you through alternative means or at an alternative location. The
practice will make every effort to comply with reasonable requests.
However, the practice may condition its compliance by asking you
for information regarding the procurement of payment or specific
information regarding an alternative address or other method of
contact. You are not required to provide an explanation for your
request. Requests should be made in writing to the practice’s
Privacy Officer.
The right to request an amendment of your protected health information.
During the time that the practice holds your PHI , you may request
an amendment of your information in a designated record set. The
practice may deny your request in some instances. However, should
the practice deny your request for amendment, you have the right
to file a statement of disagreement with the practice. In turn,
the practice may develop a rebuttal to your statement. If it does
so, the practice will provide you with a copy of the rebuttal. Requests
for amendment must be submitted in writing to the practice’s
Privacy Officer. Your written request must supply a reason to support
the requested amendments.
The right to request an accounting of certain disclosures. You
have the right to request an accounting of the practice’s disclosures
of your PHI made for purposes other than treatment, payment or health
care operations as described in this Notice. The practice is not
required to account for disclosures (1) which you requested, (2)
which you authorized by signing an authorization form, (3) for a
facility directory, (4) to friends or family members involved in
your care, and (5) certain other disclosures the practice is permitted
to make without your authorization. The request for an accounting
must be made in writing to our Privacy Officer and should state
the time period for which you wish the accounting to include up
to a six year period. The practice is not required to provide an
accounting for disclosures that take place prior to April 14, 2003.
The practice will not charge you for the first accounting you request
of any 12-month period. Subsequent accountings may require a fee
based on the practice’s reasonable costs for compliance of
the request.
The right to obtain a paper copy of this Notice. The practice will
provide a separate paper copy of this Notice upon request even if
you have already been given a copy of it or have agreed to review
it electronically.
VI. The Practice’s Duties
The practice is required to ensure the privacy of your health information
and to provide you with this Notice of your rights and the practice’s
duties and procedures regarding your privacy. The practice must
abide by the terms of this Notice, as may be amended periodically.
The practice reserves the right to change the terms of this
Notice and to make the new Notice provisions effective for all
PHI that the practice collects and maintains. If the practice alters
its Notice, the practice will provide a copy of the revised Notice
through regular mail or in-person contact.
VII. Complaints
If you believe that your privacy rights have been violated, you
have the right to relate complaints to the practice and to the Secretary
of the Department of Health and Human Services. You may provide
complaints to the practice verbally or in writing. Such complaints
should be directed to the practice's Privacy Officer. The practice
encourages you to relate any concerns you may have regarding the
privacy of your information and you will not be retaliated against
in any way for filing a complaint.
VIII. Contact Person
The practice's contact person regarding the practice’s duties
and your rights under the HIPAA privacy regulations is the Privacy
Officer. The Privacy Officer can provide information regarding issues
related to this Notice by request. Complaints to the practice should
be directed to the Privacy Officer at the following address:
Michael Chandler, M.D., Gary Stadtmauer, M.D.,
Elizabeth Loewy, M.D. and Olga Belostotsky, M.D.
115 East 61 St.
New York, NY 10021
ATTN: Privacy Officer
The Privacy Officer can be contacted by telephone at 212-486-6715
IX. Effective Date
This Notice is effective on April 14, 2003.
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