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 REVIEW IT CAREFULLY.
I. What this Is
This Notice describes the privacy practices of Harold Weinberg, MD_(the "Practice").
II. Our Privacy Obligations
We are required by law to maintain the privacy of medical and health information
about you (“Protected Health Information” or “PHI”) and to provide you with
this Notice of our legal duties and privacy practices with respect to PHI.
When we use or disclose PHI, we are required to abide by the terms of this
Notice (or other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written
Authorization
In certain situations, which we will describe in Section IV below, we must
obtain your written authorization in order to use and/or disclose your PHI.
However, we do not need any type of authorization from you for the following
uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health
Care Operations. We may use and disclose PHI in order to treat you,
obtain payment for services provided to you and conduct our “health care
operations” (e.g., internal administration, quality improvement and customer
service) as detailed below:
Treatment. We use and disclose PHI to provide treatment and other
services to you--for example, to diagnose and treat your injury or illness.
In addition, we may contact you to provide appointment reminders or information
about treatment alternatives or other health-related benefits and services
that may be of interest to you. We may also disclose PHI to other providers
involved in your treatment.
Payment. We may use and disclose PHI to obtain payment for services
that we provide to you--for example, disclosures to claim and obtain payment
from your health insurer, HMO, or other company that arranges or pays the
cost of some or all of your health care (“Your Payor”), or to verify that
Your Payor will pay for health care.
Health Care Operations. We may use and disclose PHI for our health
care operations, which include internal administration and planning and various
activities that improve the quality and cost effectiveness of the care that
we deliver to you. For example, we may use PHI to evaluate the quality
and competence of our physicians, nurses and other health care workers.
We may disclose PHI to our office manager in order to resolve any complaints
you may have and ensure that you have a pleasant visit with us.
We may also disclose PHI to your other health care providers when such PHI
is required for them to treat you, receive payment for services they render
to you, or conduct certain health care operations, such as quality assessment
and improvement activities, reviewing the quality and competence of health
care professionals, or for health care fraud and abuse detection or compliance.
B. Disclosure to Relatives Close Friends and Other Caregivers.
We may use or disclose PHI to a family member, other relative, a close personal
friend or any other person identified by you when you are present for, or
otherwise available prior to, the disclosure. If you object to such
uses or disclosures, please notify the Office Manager.
If you are not present, you are incapacitated,
or in an emergency circumstance, we may exercise our professional judgment
to determine whether a disclosure is in your best interests. If we
disclose information to a family member, other relative or a close personal
friend, we would disclose only information that is directly relevant to the
person’s involvement with your health care or payment related to your health
care. We may also disclose PHI in order to notify (or assist in notifying)
such persons of your location, general condition or death.
C. Public Health Activities. We may disclose PHI
for the following public health activities: (1) to report health information
to public health authorities for the purpose of preventing or controlling
disease, injury or disability; (2) to report child abuse and neglect to public
health authorities or other government authorities authorized by law to receive
such reports; (3) to report information about products and services under
the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a
person who may have been exposed to a communicable disease or may otherwise
be at risk of contracting or spreading a disease or condition; and (5) to
report information to your employer as required under laws addressing work-related
illnesses and injuries or workplace medical surveillance.
D. Victims of Abuse, Neglect or Domestic Violence.
If we reasonably believe you are a victim of abuse, neglect or domestic violence,
we may disclose PHI to a governmental authority, including a social service
or protective services agency, authorized by law to receive reports of such
abuse, neglect, or domestic violence.
E. Health Oversight Activities. We may disclose PHI
to a health oversight agency that oversees the health care system and is
charged with responsibility for ensuring compliance with the rules of government
health programs such as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. We may
disclose PHI in the course of a judicial or administrative proceeding in
response to a legal order or other lawful process.
G. Law Enforcement Officials. We may disclose PHI
to the police or other law enforcement officials as required or permitted
or permitted by law or in compliance with a court order or a grand jury or
administrative subpoena.
H. Decedents. We may disclose PHI to a coroner or
medical examiner as authorized by law.
I. Organ and Tissue Procurement. We may disclose
PHI to organizations that facilitate organ, eye or tissue procurement, banking
or transplantation.
J. Research. We may use or disclose PHI without your
consent or authorization if an Institutional Review Board/Privacy Board approves
a waiver of authorization for disclosure.
K. Health or Safety. We may use or disclose PHI to
prevent or lessen a serious and imminent threat to a person’s or the public’s
health or safety.
L. Specialized Government Functions. We may use and
disclose PHI to units of the government with special functions, such as the
U.S. military or the U.S. Department of State under certain circumstances
required by law.
M. Workers’ Compensation. We may disclose PHI as
authorized by and to the extent necessary to comply with laws relating to
workers' compensation or other similar programs.
N. As required by law. We may
use and disclose PHI when required to do so by any other law not already
referred to in the preceding categories.
IV. Use and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For
any purpose other than the ones described in Section III, we only may use
or disclose PHI when (1) you give us your authorization on our authorization
form (“Your Authorization”). For instance, you will need to execute
an authorization form before we can send your PHI to your life insurance
company, to your child’s camp or school, or to the attorney representing
the other party in litigation in which you are involved. [Implementation
Tip: a provider that maintains psychotherapy notes may wish to state that
the individual’s authorization is necessary to use psychotherapy notes for
treatment, payment and health care operations under certain circumstances
under 45 C.F.R. § 164.508(a)(2).]
B. Special Authorization. Confidential HIV-related
information (for example, information regarding whether you have ever been
the subject of an HIV test, have HIV infection, HIV-related illness or AIDS,
or any information which could indicate that you have ever been potentially
exposed to HIV) will never be used or disclosed to any person without your
specific written authorization, except to certain other persons who need
to know such information in connection with your medical care, and, in certain
limited circumstances, to public health or other government officials (as
required by law), to persons specified in a special court order, to insurers
as necessary for payment for your care or treatment, or to certain persons
with whom you have had sexual contact or have shared needles or syringes
(in accordance with a specified process set forth in New York State law).
This special written authorization (“Your Special Authorization”) is a New
York State approved form which is a separate document from Your Authorization.
There is only one type of disclosure of confidential HIV
related information which is permitted with Your Authorization, as opposed
to Your Special Authorization: disclosures to a third party payor for
any reason other than obtaining payment for health care services rendered
to you.
C. Marketing Communications. We must also obtain your written
authorization (“Your Marketing Authorization”) prior to using your PHI to
send you any marketing materials. (We can, however, provide you with
marketing materials in a face-to-face encounter, without obtaining Your Marketing
Authorization. We are also permitted to give you a promotional gift
of nominal value, if we so choose, without obtaining Your Marketing Authorization.)
In addition, we may communicate with you about products or services relating
to your treatment, case management or care coordination, or alternative treatments,
therapies, providers or care settings. We may use or disclose PHI to
identify health-related services and products that may be beneficial to your
health and then contact you about the services and products.
V. Your Individual Rights
A. For Further Information; Complaints. If you desire
further information about your privacy rights, are concerned that we have
violated your privacy rights or disagree with a decision that we made about
access to PHI, you may contact our Office Manager. You may also file
written complaints with the Director, Office for Civil Rights of the U.S.
Department of Health and Human Services. Upon request, the Office Manager
will provide you with the correct address for the Director. We will
not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Additional Restrictions. You
may request restrictions on our use and disclosure of PHI (1) for treatment,
payment and health care operations, (2) to individuals (such as a family
member, other relative, close personal friend or any other person identified
by you) involved with your care or with payment related to your care, or
(3) to notify or assist in the notification of such individuals regarding
your location and general condition. All requests for such restrictions
must be made in writing. While we will consider all requests for additional
restrictions carefully, we are not required to agree to a requested restriction.
If you wish to request additional restrictions, please obtain a request form
from our Office Manager and submit the completed form to the Office Manager.
We will send you a written response.
C. Right to Receive Confidential Communications.
You may request, and we will accommodate, any reasonable written request
for you to receive PHI by alternative means of communication or at alternative
locations.
D. Right to Inspect and Copy Your Health Information.
You may request access to your medical record file and billing records maintained
by us in order to inspect and request copies of the records. All requests
for access must be made in writing. Under limited circumstances, we
may deny you access to your records. If you desire access to your records,
please obtain a record request form from the Office Manager and submit the
completed form to the Office Manager. If you request copies, we will
charge you [$0.75___ (___75__ cents)] for each page. [Implementation
Tip: This must be no more than $0.75 per page.] We will also
charge you for our postage costs, if you request that we mail the copies
to you.
You should take note that, if you are a parent or legal guardian of a minor,
certain portions of the minor’s medical record will not be accessible to
you (for example, records relating to venereal disease, abortion, or care
and treatment to which the minor is permitted to consent himself/herself
(without your consent) such as HIV testing, sexually transmitted disease
diagnosis and treatment, chemical dependence treatment, prenatal care, care
received by a married minor, and contraception and/or family planning services).
E. Right to Revoke Your Authorization. You may revoke
Your Authorization, Your Special Authorization, or Your Marketing Authorization,
except to the extent that we have taken action in reliance upon it, by delivering
a written revocation statement to the Office Manager identified below.
[A form of Written Revocation is available upon request from the Office Manager.]
F. Right to Amend Your Records. You have the right
to request that we amend PHI maintained in your medical record file or billing
records. If you desire to amend your records, please obtain an amendment
request form from the Office Manager and submit the completed form to the
Office Manager. All requests for amendments must be in writing.
We will comply with your request unless we believe that the information that
would be amended is accurate and complete or other special circumstances
apply.
G. Right to Receive An Accounting of Disclosures.
Upon written request, you may obtain an accounting of certain disclosures
of PHI made by us during any period of time prior to the date of your request
provided such period does not exceed six years and does not apply to disclosures
that occurred prior to April 14, 2003. If you request an accounting more
than once during a twelve (12) month period, we will charge you [$0.75_ per
page] of the accounting statement. [Implementation Tip: This must be
a reasonable, cost-based fee].
H. Right to Receive Paper Copy of this Notice. Upon
written request, you may obtain a paper copy of this Notice, even if you
agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April
14, 2003.
B. Right to Change Terms of this Notice. We may change
the terms of this Notice at any time. If we change this Notice, we
may make the new notice terms effective for all PHI that we maintain, including
any information created or received prior to issuing the new notice.
If we change this Notice, we will post the revised notice in waiting areas
of the Practice [and on our Internet site at www.haroldweinbergmd.com].
You may also obtain any revised notice by contacting the Office Manager.
VII. Office Manager
You may contact the Office Manager at:
Harold Heinberg,MD
650 First Avenue
New York, NY 10016
Telephone Number: 212 213 9339