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Pibly
Residential Programs, Inc.
NOTICE OF PRIVACY
PRACTICES
EFFECTIVE DATE APRIL
14, 2003
UNDER A FEDERAL LAW CALLED THE HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), WE ARE LEGALLY REQUIRED TO
PROTECT THE PRIVACY OF YOUR IDENTIFIABLE HEALTH INFORMATION. WE ARE ALSO
REQUIRED TO PROVIDE YOU WITH THIS NOTICE OF PRIVACY PRACTICES TO
EXPLAIN HOW, WHEN, AND WHY WE MAY USE AND DISCLOSE YOUR PROTECTED 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.
WHO WILL FOLLOW THIS NOTICE:
The privacy practices described in this notice will be followed by:
• Any health care professional or other treatment provider who
treats you at any of our locations;
• All employees, health care professionals, trainees, students or
volunteers at any of our locations;
• Any business associates of our programs
OUR DUTIES TO YOU
REGARDING PROTECTED HEALTH INFORMATION:
Protected health information is individually
identifiable health information that relates to your past, present or future
physical or mental health or condition and related health care services. We are
required by law to do the following:
-
Keep your protected health
information private.
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Give you this notice of our
legal duties and privacy practices related to the use and disclosure of your
protected health information.
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Follow the terms of the
notice currently in effect.
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Communicate to you any
changes we may make in this notice.
CHANGES TO THIS
NOTICE:
We may change our policies at any time.
Therefore, we reserve the right to also change this notice. Changes will apply
to health information we already hold as well as new information we receive
after the change occurs. Should any changes occur, we will post the new notice
on this website. You will be offered a copy of the current
notice and will also be asked to acknowledge in writing your receipt of this
notice.
HOW WE MAY USE OR
DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
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We may use or disclose your
protected health information for
treatment
(to a physician or health care provider for continued care or referral),
payment
(to insurance companies for payment or approval of services), and
health care
operations
(for quality assurance or potential landlords).
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We may use or disclose your
protected health information
without
your prior
authorization if law or regulations require such disclosure for:
public health
purposes, audits or inspections, abuse or neglect, medical examiner, and
emergencies. We may also disclose protected health information
when required by
law (in
response to a request by law enforcement officials, in response to a
judicial or administrative order, or to prevent harm of any individual).
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Unless you object to any of
the following, we may contact you for
appointments by either telephone or
mail, or to
tell you of
health-related benefits or services
that may be of interest to you.
-
We may disclose your
protected health information about you to
a
friend or family member who is involved in your
care
or to disaster relief authorities so that your family can be notified of
your location and condition.
SPECIAL PROTECTIONS
FOR HIV, ALCOHOL, AND SUBSTANCE ABUSE, MENTAL HEALTH, AND GENETIC INFORMATION:
Special privacy
protections apply to HIV related information, alcohol and substance abuse
treatment information, mental health information, and genetic information.
Some parts of this Notice may not apply to these types of information. If any of
your services contain this information, you will be provided with a separate
authorization before any release of this information occurs.
OTHER USES OF
PROTECTED HEALTH INFORMATION:
In any other situation not covered by this
notice, we will ask for your written authorization before using or disclosing
your protected health information. If you chose to authorize use or disclosure,
you may later revoke that authorization by notifying us in writing of your
decision.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION:
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In most cases,
you have the
right to look at or get a copy of your protected health information
that we use to make
decisions about your care. If you request a copy of your record, we may
charge a fee for the cost of copying, mailing, or other related supplies and
we will advise you of the exact fee. If we deny your request to review or
obtain a copy of your protected health information you may submit a written
request for a review of that decision.
-
If you believe that the
information we have about you is incorrect or incomplete,
you have the right
to request an amendment to your record, in writing, that provides your reasons for this request. We could
deny your request for an amendment if the information was not created by our
agency, if it is not part of the information that is maintained by us, or if
we determine that the information is correct. You may appeal, in writing, a
decision by us not to amend your record.
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You have the
right to an accounting of disclosures we have made of your protected health
information.
This right applies to disclosures made for purposes other than treatment,
payment, or health care operations as described in this Notice and excludes
disclosures made to yourself or where you specifically authorized a
disclosure in writing. The accounting will only include disclosures made on
or after April 14, 2003, and no more than 6 years prior to the date of your
request. The first accounting request in a 12-month period is free of
charge; other requests will be charged according to the cost of producing
this information. You will be informed of the cost at the time of your
request.
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You have the
right to obtain a copy of this Notice whether or not you have received this notice
electronically.
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You have the
right to request that your protected health information be communicated to
you by alternative means, such as using an address or phone number other than
your own. Requests must be in writing. We will accommodate reasonable
requests, when possible, and when payment information has been determined
and verified.
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You have the
right to request, in writing, that we not disclose any part of your
protected health information for treatment, payment, healthcare operations,
or to persons involved in your care, except when specifically authorized by you, when
required by law, or in an emergency. We will consider your request
but we are not
obligated to accept it. You will be informed of our decision regarding your
request.
COMPLAINTS:
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If you believe that your
privacy rights have been violated, you may file a written complaint with our
Privacy Officer.
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You may also file a written
complaint with the U.S. Department of Health and Human Services' Office of
Civil Rights.
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Under no circumstances will
you be retaliated against for filing a complaint with our Privacy Officer or
with the Office of Civil Rights.
PRIVACY OFFICER:
Manuel Morales
Pibly Residential
Programs, Inc.
1416 Williamsbridge Road
Bronx, New York 10461
Phone: (718) 863-4100 x617
E-Mail:
manuel@pibly.org
OFFICE FOR CIVIL RIGHTS
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
26 Federal Plaza - Suite 3313
New York, NY 10278
(212) 264-3313; (212) 264-2355 (TDD)
(212) 264-3039 FAX
http://www.hhs.gov/ocr/privacy/hipaa/complaints/
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