Conifer Park 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 READ IT CAREFULLY.
Conifer Park has adopted the following policies and procedures for protection of the privacy of the people we serve.
Our Obligation to You
We at Conifer Park respect your privacy. This is part of our code of ethics. We are required by law to maintain the privacy of “protected health information” about you, to notify you of our legal duties and your legal rights, and to follow the privacy policies described in this notice. “Protected health information” means any information that we create or receive that identifies you and relates to your health or payment for services to you.
Use and Disclosure of Information about You
Use and disclosure for treatment, payment and health care operations.
We will use your protected health information and disclose it to others as necessary to provide treatment to you. Here are some examples:
- Various members of our staff may see your clinical record in the course of our care for you. This includes clinical assistants, nurses, physicians and other therapists.
- It may be necessary to send blood or tissue samples to a laboratory for analysis to help us evaluate your medical condition.
- We may provide information to your health plan or another treatment provider in order to arrange for a referral or clinical consultation.
- We will contact you to remind you of appointments.
- We may contact you to tell you about treatment services that we offer that might be of benefit to you
We will use or disclose your protected health information as needed to arrange for payment for service to you. For example, information about your diagnosis and the service we render is included in the bills that we submit to your health insurance plan. Your health plan may require health information in order to confirm that the service rendered is covered by your benefit program and
medically necessary. A health care provider that delivers service to you, such as a clinical laboratory, may need information about you in order to arrange for payment for its services.
It may also be necessary to use or disclose protected health information for our health care operations or those of another organization that has a relationship with you. For example, our quality assurance staff reviews records to be sure that we deliver appropriate treatment of high quality. Your health plan may wish to review your records to be sure that we meet national standards for quality of care.
It is our policy to obtain specific written permission for every disclosure of protected health information to third parties. You will be asked to sign a general consent for disclosure for treatment, payment and health care operations. For all other third parties, except as required by state or federal law, you will be asked to sign a specific Authorization form for each person or organization that receives the information.
Emergencies. If there is an emergency, we will disclose your protected health information as needed to enable people to care for you.
Disclosure to your family and friends. If you are an adult, you have the right to control disclosure of information about you to any other person, including family members or friends. If you ask us to keep your information confidential, we will respect your wishes. But if you don’t object, we will share information with family members or friends involved in your care as needed to enable them to
Disclosure to health oversight agencies. We are legally obligated to disclose protected health information to certain government agencies, including the federal Department of Health and Human Services.
Disclosures to child protection agencies. We will disclose protected health information as needed to comply with state law requiring reports of suspected incidents of child abuse or neglect.
Other disclosures without written permission. There are other circumstances in which we may be required by law to disclose protected health information without your permission. They include disclosures made:
- Pursuant to court order;
- To public health authorities;
- To law enforcement officials in some circumstances;
- To coroners, medical examiners and funeral directors;
- To researchers involved in approved research projects;
- As necessary to care for you in a medical or psychiatric emergency;
- As otherwise required by law.
Disclosures with your permission. No other disclosure of protected health information will be made unless you give written Authorization for the specific disclosure.
Your Legal Rights
Right to request confidential communications. You may request that communications to you, such as appointment reminders, bills, or explanations of health benefits be made in a confidential manner. We will accommodate any such request, as long as you provide a means for us to process payment transactions.
Right to request restrictions on use and disclosure of your information. You have the right to request restrictions on our use of your protected health information for particular purposes, or our disclosure of that information to certain third parties. We are not obligated to agree to a requested restriction, but we will consider your request.
Right to revoke a Consent or Authorization. You may revoke a written Consent or Authorization for us to use or disclose your protected health information. The revocation will not affect any previous use or disclosure of your information. However, revocation of consent for sharing payment information with your insurance or managed care company my result in termination of services.
Right to review and copy record. You have the right to see records used to make decisions about you. We will allow you to review your record unless a clinical professional determines that would create a substantial risk of physical harm to you or someone else. If another person provided information about you to our clinical staff in confidence, that information may be removed from the record
before it is shared with you. We will also delete any protected health information about other people.
At your request, we will make a copy of your record for you. We will charge .75 per page for this service.
Right to append record. If you believe your record contains an error, you may ask us to append to it. If there is a mistake, a note will be entered in the record to correct the error. If not, you will be told and allowed the opportunity to add a short statement to the record explaining why you believe the record is inaccurate. This information will be included as part of the total record and shared with
others if it might affect decisions they make about you.
Right to an accounting. You have the right to an accounting of some disclosures of your protected health information to third parties. This does not include disclosures that you authorize, or disclosures that occur in the context of treatment, payment or health care operations. We will provide an accounting of other disclosures made in the preceding six years. If requested by law enforcement authorities that are conducting a criminal investigation, we will suspend accounting of disclosures made to them.
Right to a paper copy of this Notice. You have the right to a paper copy of any Notice of Privacy Practices posted on our website.
How to Exercise Your Rights
Questions about our policies and procedures, requests to exercise individual rights, and complaints should be directed to our Privacy Officer.
Our Contact Person is Patricia A. Wilcox, Privacy Officer and Director of Risk Management. Ms. Wilcox can be reached at (800) 989-6446, Ext. 8323 by phone; by mail at Conifer Park, Attn Patricia Wilcox, Director of Risk Management, 79 Glenridge Road, Glenville NY 12302; by e-mail at email@example.com; or by fax at (518) 952-8228.
Personal representatives. A “personal representative” of a patient may act on their behalf in exercising their privacy rights. This includes the parent or legal guardian of a minor. In some cases, adolescents who are “mature minors” may make their own decisions about receiving treatment and disclosure of protected health information about them. Adolescents receiving drug and alcohol
treatment must sign an authorization to release information along with their parents to release protected health information. If an adult is incapable of acting on his or her own behalf, the personal representative would ordinarily be his or her spouse or another member of the immediate family. An individual can also grant another person the right to act as his or her personal representative in an advance directive or living will.
Disclosure of protected health information to personal representatives may be limited in cases of domestic or child abuse.
If you have any complaints or concerns about our privacy policies or practices, please submit a Complaint to our Contact Person. The Contact Person will give you a form that you can use to submit a Complaint if you wish.
You can also submit a complaint to the United States Department of Health and Human Services. Send your complaint to:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019
We will never retaliate against you for filing a complaint
These policies and procedures were approved by our Executive Committee on 03/27/03. They are effective as of April 14, 2003.
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Additionally, these records are protected by 45 CFR Parts 160 and 164 (HIPAA).