USE AND DISCLOSURE OF YOUR HEALTH INFORMATION IN SPECIAL CIRCUMSTANCES
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 for other similar programs established by law.
Correctional Institutions: Should you be an inmate of a correctional institute 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.
Public Health Risks: Our practice may disclose your health information to public health authorities that are authorized by law to collect information.
National Security: Our practice may disclose your health information to federal officials for intelligence and national security activities authorized by law.
Military: We may disclose health information if you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.
Please review this notice carefully.
Effective Date: 7/1/2006
Revised: 9/26/2008
NOTICE OF PRIVACY POLICY
North Country ENT PC
2 Mountain Ledge Drive
Gansevoort, NY 12831
Phone: 518-587-6610
Fax: 518-226-0890
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Each time you visit with us, a record of your visit is made. Typically, this record contains your symptoms, examination and diagnoses, treatment and 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 many health professionals who contribute to your care.
- Legal documents describing the care you received.
- Means by which you or a third-party payer can verify that services billed were actually provided.
- Source of information for public health officials charged to improve the health of the state and nation.
Some clinicians may use this information to contact you for the purpose of:
- Providing appointment reminders.
- Describing or recommending treatment alternatives.
INFORMATION RIGHTS
Although your health record in the physical property of North Country ENT, PC, the information belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information.
- Obtain paper copy of the notice of information practices upon request.
- Inspect a copy your health record as provided by 45 CFR, 164.524.
- Obtain an accounting of disclosures of your health information as provided by 45 CFR 164.528.
- Amend you health records as provided by 45 CFR 164.526.
- Request confidential communication of your health information by alternative means or at alternative locations as provided by 45 CFR 164.522 (b)
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken place as provided by 45 CFR 164.508 (b) (5).
OUR RESPONSIBILITIES
This organization is required to:
- Maintain the privacy of your health information.
- Provide you with this 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.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notice in our facility containing the effective date. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon request.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact our privacy officer, Penny Sciancalepore at 518-587-6610. If you believe your privacy rights have been violated, you can file a complaint with our privacy officer or the office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either our group or the Office of Civil Rights. The address is as follows:
Office for Civil Rights
U.S. Department of Health and Human Services
26 Federal Plaza, Suite 3312
New York, NY 10278
USE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
We will use your health information for regular health operations, treatment, and disclosures required by law.
We will use your health information for payment:
For example, a bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as our diagnosis, procedures and/or payments.
For example: A bill may be sent to an outside agency for the purpose of collecting outstanding balances on delinquent accounts. The information on or accompanying the bill may include information that identifies you, dates of service and patient/insurance payment history.
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