Privacy Policy

Notice of Privacy Practices


Purpose: This form, Notice of Privacy Practices, presents the
information that federal law requires us to give our patients regarding our
privacy practices.

We must provide this Notice to each
patient beginning no later than the date of our first service delivery to the
patient, including service delivered electronically, after April 14, 2003. We
must make a good-faith attempt to obtain written acknowledgement of receipt of
the Notice from the patient. We must also have the Notice available at the
office for patients to request to take with them. We must post the Notice in
our office in a clear and prominent location where it is reasonable to expect
any patients seeking service from us to be able to read the Notice. Whenever
the Notice is revised, we must make the Notice available upon request on or
after the effective date of the revision in a manner consistent with the above
instructions. Thereafter, we must distribute the Notice to each new patient at
the time of service delivery and to any person requesting a Notice. We must
also post the revised Notice in our office as discussed above.


NOTICE OF PRIVACY PRACTICES THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE
PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.


OUR LEGAL DUTY

We are required by applicable
federal and state law to maintain the privacy of your health information. We
are also required to give you this Notice about our privacy practices, our
legal duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while it is in
effect. This Notice takes effect (04/14/03), and will remain in effect until we
replace it.

We reserve the right to change our
privacy practices and the terms of this Notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the
changes in our privacy practices and the new terms of our Notice effective for
all health information that we maintain, including health information we
created or received before we made the changes. Before we make a significant
change in our privacy practices, we will change this Notice and make the new
Notice available upon request.

You may request a copy of our Notice
at any time. For more information about our privacy practices, or for
additional copies of this Notice, please contact us using the information
listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH
INFORMATION

We use and disclose health information about you for treatment, payment, and
healthcare operations. For example:

Treatment: We may use or disclose your health information to a
physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for
services we provide to you.

Healthcare Operations: We may use and disclose your health information in
connection with our healthcare operations. Healthcare operations include
quality assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating practitioner and
provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for
treatment, payment or healthcare operations, you may give us written
authorization to use your health information or to disclose it to anyone for
any purpose. If you give us an authorization, you may revoke it in writing at
any time. Your revocation will not affect any use or disclosures permitted by
your authorization while it was in effect. Unless you give us a written
authorization, we cannot use or disclose your health information for any reason
except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as
described in the Patient Rights section of this Notice. We may disclose your
health information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare, but
only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or
assist in the notification of (including identifying or locating) a family
member, your personal representative or another person responsible for your
care, of your location, your general condition, or death. If you are present,
then prior to use or disclosure of your health information, we will provide you
with an opportunity to object to such uses or disclosures. In the event of your
incapacity or emergency circumstances, we will disclose health information
based on a determination using our professional judgment disclosing only health
information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgment and our experience with
common practice to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization.
Required by Law: We may use or disclose your health information when we are
required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate
authorities if we reasonably believe that you are a possible victim of abuse,
neglect, or domestic violence or the possible victim of other crimes. We may
disclose your health information to the extent necessary to avert a serious
threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health
information of Armed Forces personnel under certain circumstances. We may
disclose to authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security activities. We
may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under
certain circumstances.

 


PATIENT RIGHTS

Access: You have the right to look at or get copies of your health
information, with limited exceptions. You may request that we provide copies in
a format other than photocopies. We will use the format you request unless we
cannot practicably do so. (You must make a request in writing to obtain access
to your health information. You may obtain a form to request access by using
the contact information listed at the end of this Notice. We will charge you a
reasonable cost-based fee for expenses such as copies and staff time. You may also
request access by sending us a letter to the address at the end of this Notice.
If you request copies, we will charge you $ 50, plus postage if you want the
copies mailed to you. If you request an alternative format, we will charge a
cost-based fee for providing your health information in that format. If you
prefer, we will prepare a summary or an explanation of your health information
for a fee. Contact us using the information listed at the end of this Notice
for a full explanation of our fee structure.

Restriction: You have the right to request that we place additional
restrictions on our use or disclosure of your health information. We are not
required to agree to these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you
about your health information by alternative means or to alternative locations.
{You must make your request in writing.} Your request must specify the alternative
means or location, and provide satisfactory explanation how payments will be
handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health
information. (Your request must be in writing, and it must explain why the
information should be amended.) We may deny your request under certain
circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic
mail (e-mail), you are entitled to receive this Notice in written form.


QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or
concerns, please contact us.

If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made
about access to your health information or in response to a request you made to
amend or restrict the use or disclosure of your health information or to have
us communicate with you by alternative means or at alternative locations, you
may complain to us using the contact information listed at the end of this
Notice. You also may submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy
of your health information. We will not retaliate in any way if you choose to
file a complaint with us or with the U.S. Department of Health and Human
Services.

Contact Officer: Joanne Payne
Telephone: (845) 562-1108
E-mail: [email protected]
Address: 4 Hudson Valley Professional Plaza  
Newburgh, NY  12550