NOTICE OF PATIENT PRIVACY RIGHTS
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.
This Office/Practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and care and
Treatment you receive from the Practice. The creation of a record detailing the care and
Services you receive helps this office to provide you with quality health care. This Notice
Details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.
The Office/Practice may use and/or disclose your PHI for the following purposes:
(a) Treatment – In order to provide you with the health care you require, the Office/Practice will provide your PHI to those health care professionals, whether on the Practice’s
staff or not, directly involved in your care so that they may understand your health
condition and needs. For example, a physician treating you for lower back pain may
need to know the results of your latest physician examination by this office.
(b) Payment – In order to get paid for services provided to you, the Office/Practice will
provide your PHI, directly or through a billing service, to appropriate third party payors,
pursuant to their billing and payment requirements. For example, the Practice may need
to provide the Medicare program with information about health care services that you
received from the Practice so that the Practice can be properly reimbursed. The Practice
may also need to tell your insurance plan about treatment you are going to receive so
that it can determine whether or not it will cover the treatment expense.
(c) Health Care Operations – In order for the Office/Practice to operate in accordance
with applicable law and insurance requirements and in order for the Practice to continue
to provide quality and efficient care, it may be necessary for the Practice to compile, use
and/or disclose your PHI. For example, the Practice may use your PHI in order to
evaluate the performance of the Practice’s personnel in providing care to you.
The Office/Practice may also use and/or disclose your PHI without your specific authorization
in the following additional instances:
(a) De-identified Information – Information that does not identify you and, even without
your name, cannot be used to identify you.
(b) Business Associate – To a business associate if the Office/Practice obtains satisfactory
written assurance, in accordance with applicable law, that the business associate will
appropriately safeguard your PHI. A business associate is an entity that assists the
Practice in undertaking some essential function, such as a billing company that assists
the office in submitting claims for payment to insurance companies or other payers.
(c) Personal Representative - To a person who, under applicable law, has the authority
to represent you in making decisions related to your health care.
(d) Emergency Situations –
(1) for the purpose of obtaining or rendering emergency treatment to you if the
opportunity for you to object cannot be obtained due to your incapacity or
emergent treatment circumstances and the treatment is consistent with your
prior expressed preferences and is in your best interest; or
(2) to a public or private entity authorized by law or by its charter to assist in disaster
relief efforts, for the purpose of coordinating your care with such entities in an
(e) Public Health Activities – Such activities include, for example, information collected
by a public health authority, as authorized by law, to prevent or control disease.
(f) Abuse, Neglect or Domestic Violence – To a government authority if the
Office/Practice is required by law to make such disclosure. If the Practice is
authorized by law to make such a disclosure, it will do so if it believes that the
disclosure is necessary to prevent serious harm.
(g) Health Oversight Activities – Such activities, which must be required by law,
involve government agencies and may include, for example, criminal investigations,
disciplinary actions, or general oversight activities relating to the community’s
health care system.
(h) Judicial and Administrative Proceeding – For example, the Office/Practice maybe
required to disclose your PHI in response to a court order or a lawfully issued
(i ) Law Enforcement Purposes - In certain instances, your PHI may have to be
disclosed to a law enforcement official. For example, your PHI may be the
subject of a grand jury subpoena. Or, the Practice may disclose your PHI if the
believes your death was the result of criminal conduct.
(j ) Coroner or Medical Examiner - The Office/Practice may disclose your PHI to
a coroner or medical examiner for the purpose of identifying you or determining
your cause of death.
(k) Organ, Eye or Tissue Donation – If you are an organ donor, the Practice may
disclose your PHI to the entity to whom you have agreed to donate your organs.
(l ) Research - If the Office/Practice is involved in research activities, your PHI may
be used, but such use is subject to numerous governmental requirements intended
to protect the privacy of your PHI.
(m) Avert A Threat to Health or Safety - The Office/Practice may disclose your PHI
if it believes disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public and disclosure is to an
individual who is reasonably able to prevent or lessen the threat.
(n) Specialized Government Functions – This refers to disclosure of PHI that relates
primarily to military and veteran activity.
(o) Workers’ Compensation – If you are involved in a Workers’ Compensation claim,
the Office/Practice may be required to disclose your PHI to an individual or entity
that is part of the Workers’ Compensation system.
(p) National Security and Intelligence Activities – The Office/Practice may disclose your
PHI in order to provide authorized governmental officials with necessary intelligence
information for national security activities and purposes authorized by law.
(q) Military and Veterans – If you are a member of the armed forces, the Office/Practice
may disclose your PHI as required by the military command authorities.
(r) Fundraising – In order to conduct or assist business associates and/or other
institutionally related foundations raise funds for a charitable purpose, such a local
hospital, the American Red Cross or other private or public disaster relief agency,
Breast Caner or AIDS-related research, etc. this Office/Practice may give out
demographic information about you as well as any dates health care was provided
to you without your specific authorization. However, if the Office/Practice does
engage in any fundraising activity, it must include instructions in the fundraising
materials indicating how you may decline to receive any further fundraising
communications from the Office/Practice.
The Office/Practice may, from time to time, contact you to provide appointment
reminder or information about treatment alternatives or other health-related benefits and
services that may be of interest to you. The following appointment reminders are used by the
Practice: a) a postcard mailed to you at the address provided by you; and b) telephoning your
home and leaving a message on your answering machine or with the individual answering the
The Office/Practice maintains a directory of and sign-in log for individuals seeking
care and treatment in the office. Directory and sign-in log are located in a position where staff
can readily see who is seeking care in the office, as well as the individual’s location within the
Practice’s office suite. This information may be seen by, and is accessible to, others who are
seeking care or services in the Practice’s offices.
The Office/Practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care. The Practice may also use
or disclose your PHI to notify or assist in the notification (including identifying or locating) a
family member, a personal representative, or another person responsible for your care, of your
location, general condition or death. However, in bother cases, the following conditions will apply:
(a) If you are present at or prior to the use or disclosure of your PHI, the Office/Practice
may use or disclose your PHI if you agree, or if the Practice can reasonably infer from
the circumstances, based on the exercise of its professional judgment, that you do not
object to the use or disclosure.
(b) If you are not present, the Office/Practice will, in the exercise of professional
judgment, determine whether the use of disclosure is in your best interests and, if so,
disclose only the PHI that is directly relevant to the person’s involvement with your
Uses and/or disclosures, other than those described above, will be made only with
your written Authorization.
You have the right to:
(a) Revoke any Authorization in writing, at any time. To request a revocation, you must
submit a written request to the Practice’s Privacy Office.
(b) Request restrictions on certain use and/or disclosure of your PHI as provided by law.
However, the Office/Practice is not obligated to agree to any requested restrictions.
To request restrictions, you must submit a written request to the Practice’s Privacy
Officer. In your written request, you must inform the Practice of what information
you want to limit, whether you want to limit the Practice’s use or disclosure, or both,
and to whom you want the limits to apply. If the Practice agrees to your request, the
Practice will comply with your request unless the information is needed in order to
provide you with emergency treatment.
(c) Receive confidential communications or PHI by alternative means or at alternative
locations. You must make your request in writing to the Practice’s Privacy Officer.
The Practice will accommodate all reasonable requests.
(d) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you
must submit a written request to the Practice’s Privacy Officer. The Practice can
charge you a fee for the cost of copying, mailing or other supplies associated with
your request. In certain situations that are defined by law, the Practice may deny your
request, but you will have the right to have the denial reviewed as set forth more fully
in the written denial notice.
(e) Amend your PHI as provided by law. To request an amendment, you must submit a
written request to the Practice’s Privacy Officer. You must provide a reason that
supports your request. The Practice may deny your request if it is not in writing, if
you do not provide a reason in support of your request, if the information to be
amended was not created by the Practice (unless the individual or entity that created
the information is no longer available), if the information is not part of your PHI
maintained by the Practice, if the information is not part of the information you would
be permitted to inspect and copy, and/or if the information is accurate and complete.
If you disagree with the Practice denial, you will have the right to submit a written
statement of disagreement.
(f) Receive and accounting of disclosures of your PHI as provided by law. To request
an accounting, you must submit a written request to the Practice’s Privacy Officer.
The request must state a time period which may not be longer that six (6) years may
and may not include dates before April 14, 2003. The request should indicate in what
what form you want the list (such as a paper or electronic copy). The first list you
request within a twelve (12) month period will be free, but the Practice may charge
you for the cost of providing additional lists. The Practice will notify you of the costs
involved and you can decide to withdraw or modify your request before any costs
(g) Receive a paper copy of this Privacy Notice from the Office/Practice upon request to
the Practice’s Privacy Officer.
(h) Complain to the Office/Practice or to the Secretary of HHS if you believe your
privacy rights have been violated. To file a complaint with the Office/Practice, you
must contact the Practice’s Privacy Officer. All complaints must be in writing.
(i ) To obtain more information on, or have your questions about your rights answered,
you may contact the Practice’s Privacy Officer, Marc A. Rubins D.C. at
516-671-6225 or via email at – [email protected]
(a) Is required by federal law to maintain the privacy of your PHI and to provide you with
Privacy Notice detailing the Practice’s legal duties and privacy practices with respect
to your PHI.
(b) Is required by State law to maintain a higher level of confidentiality with respect
to certain portions of your medical information than is provided for under federal
(c) Is required to abide by the terms of the Privacy Notice.
(d) Reserves the right to change the terms of this Privacy Notice and to make the new
Privacy Notice provisions effective for all of your PHI that it maintains.
(e) Will distribute any revised Privacy Notice to you prior to implementation.
(f) Will not retaliate against you for filing a complaint.
This Notice is in effect as of: April 14, 2003.
NOTICE OF PATIENT PRIVACY RIGHTS