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EFFECTIVE APRIL 14, 2003 THIS NOTICE DESCRIBES HOW WE MAY USE AND RELEASE YOUR HEALTH INFORMATION. IT ALSO TELLS YOU ABOUT YOUR RIGHTS AND OUR REQUIREMENTS CONCERNING THE USE AND DISCLOSURE OF YOUR HEALTH INFORMATION AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1. Our Commitment to You: Pederson-Krag Center understands that the information we collect about you and your health is personal. Keeping your health information confidential and secure is one of our most important responsibilities.
We keep a record of the care and services you receive to provide you with quality care and to comply with certain legal requirements. We are committed to protecting your health information and to following all state and federal laws regarding the protection of that information.
We are required by law to:
If you have any questions about this notice, please contact our Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743, telephone, 631-920-8000, or on the web at, Pederson-Krag.org.
2. Who will follow this notice: This notice describes the practices of Pederson-Krag Center and that of:
3. Your Health Information Rights: You have the following rights regarding the health information we have about you:
Right to Inspect and Obtain Copies: You have the right to inspect and obtain a copy of health information used to make decisions about your care. Usually, this includes medical and billing records. It does not include information that is needed for civil, criminal, or administrative actions or proceedings. We may charge a fee for the costs of copying, mailing, or other expenses associated with your request.
To inspect or obtain a copy of any health information used to make decisions about you, you must submit a request in writing to: Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743, telephone, 631-920-8000.
We may deny your request to inspect and obtain a copy of your records under certain circumstances. If you are denied access to your health information, you may request that the denial be reviewed. A Medical Records Access Review Committee will review your request and the denial. The person (s) conducting the review will not include the person who initially denied your request.
Right to Amend: If you feel that the health information on file is incorrect or incomplete, you may ask us to amend that information. We may deny your request if the information: (1) was not created by us; (2) is not part of the health information kept by us; (3) is not part of the information which you would be permitted to inspect or copy; or (4) is determined to be accurate and complete. You have the right to request an amendment for as long as the information is kept by or for us.
A request for an amendment must be made in writing and submitted to: Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743. In addition, you must provide a reason that supports your request.
Right to an Accounting of Disclosures: You have the right to request a list of information releases that we have made of your health information. The list will not include: health information releases: (1) made for purposes of providing treatment to you, obtaining payment for services, or releases made for other administrative or operational purposes; (2) made for national security; (3) made to correctional and other law enforcement custodial situations; (4) made based on your written authorization; (5) made to persons who are involved in your care; or (6) made prior to April 14, 2003.
To request this list or accounting of disclosures, you must submit your request in writing to: Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743. Your request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for the purpose of treatment, payment, or health care operations. You also have the right to request that we restrict or limit health information about you that we may use or disclose to someone who is involved in your care or the payment for your care, such as a family member. For example, you could ask that we not use or disclose information about the medication you are taking to your spouse or significant other.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
To request restrictions, you must make your request in writing to: Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743. You must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).
Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at a certain phone number or by mail.
To request confidential communications, you must make your request in writing to: Administrative Offices, c/o Pederson-Krag Center, 55 Horizon Dr. Huntington, NY 11743. We will not ask the reason for your request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
4. How we may use and disclose health information about you: Your health information, which includes any information that relates to your past, present, or future health/mental health condition (which might include your photograph), may be used and released by Pederson-Krag Center for the purposes of providing treatment to you, obtaining payment for services, for administrative and operational purposes, and to evaluate the quality of the services you receive. We have listed some common examples of permitted uses and disclosures below.
For Treatment: Caregivers, such as nurses, doctors, therapists and social workers, may use your health information to determine your plan of care. Individuals and programs within Pederson-Krag Center may share health information about you to coordinate the services you may need. We may use health information about you to provide you with treatment or services.
For Payment: Pederson-Krag Center may release information about you to your health plan or health insurance carrier to obtain payment for services. We may also share your information, when appropriate, with other government programs such as Workers' Compensation, Medicaid, Medicare, or Indian Health Services to determine if you are eligible for, or to coordinate, your benefits, entitlements, and payments. We may need to disclose a limited amount of information about you to explore your financial situation for possible sources of payment for your care, but we will only do so as permitted under law. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. If you are due a refund of money because you have overpaid for our services, we may share a limited amount of your information with the NYS Office of the State Comptroller to obtain that refund for you.
For Operations: Pederson-Krag Center may use and release information about you to ensure that the services and benefits provided to you are appropriate and are high quality. We may combine health information about many individuals to research health trends, or determine what services and programs should be offered, or whether new treatments or services are useful. We may share your health information with our business partners who perform functions on our behalf. Pederson-Krag Center requires that our business partners abide by the same level of confidentiality and security as we do when handling your information.
To Keep You Informed: Unless you provide us with alternative instructions, we may contact you about reminders for treatment, medical care, or health check-ups. We may also contact you to tell you about health related benefits or services or to give you information about your health care choices.
To Other Government Agencies Providing Benefits or Services: We may release your health information to other government agencies that are providing you with benefits or services when the information is necessary for you to receive those benefits or services.
Research: We may release your health information for research projects that have been reviewed and approved by a special approval process to ensure the continued privacy and protection of the health information. We may also disclose health information about you to people preparing to conduct a research project; for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave our facility.
As Required by Law: We will disclose health information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: We may release your health information if it is necessary to prevent a serious threat to your health or safety or to the health and safety of the public or another person.
For Public Health Activities: We may disclose health information about you to public health agencies, subject to the provision of applicable state and federal law, in the following circumstances:
For Health Oversight Activities: Pederson-Krag Center may share your health information within our own agency and with other agencies for oversight activities authorized by law. Examples of these oversight activities include audits, inspections, investigations, and licensure.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may release health information about you in response to a court or administrative order. We may also release health information about you in response to a court order, subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information required.
For Law Enforcement: We may release health information to a law enforcement official:
Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner or medical examiner to carry out their duties as authorized by law (for example, to identify a deceased person or determine the cause of death). We may also release health information to funeral directors as necessary to carry out their duties.
Organ Donation: If you are an organ donor, we may release your health information to an organization that procures, banks, or transports organs for the purpose of an organ, eye, or tissue donation or transplant.
National Security and Protection of the President: We may release your health information to an authorized federal official or other authorized persons for purposes of national security, for providing protection to the President, or to conduct special investigations, as authorized by law.
Inmates/Forensic Patients: If you are an inmate of a correctional institution, or a person who is receiving care in a psychiatric hospital as a result of a criminal court order or are under the custody of a law enforcement official (that is, a forensic patient), we may release health information about you to the correctional institution or law enforcement official. The information released must be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution or psychiatric hospital.
To the Military: If you are a veteran or a current member of the armed forces, we may release health information as required by military command or Veterans Administration authorities.
If you do not object, and the situation is not an emergency and disclosure is not otherwise prohibited by stricter laws, we are permitted to release your health information under the following circumstances:
To Individuals Involved in Your Care: To a family member, other relative, friend, or other person who you have identified to be involved in your health care or the payment of your health care. To Family: To notify a family member, personal representative or person responsible for your care, of your location, general condition, or death. To Disaster Relief Agencies: To an agency authorized by law to assist in disaster relief efforts. 5. What is NOT Covered Under this Notice?
Confidential HIV Related Information: Under New York State Law, confidential HIV- related information (information concerning whether or not you have had an HIV- related test, have HIV infection or HIV- related illness, or AIDS, or which could indicate a person has been potentially exposed to HIV), cannot be disclosed except to those people you authorize in writing to have it.
Alcohol or Substance Abuse Treatment Information: If you have received alcohol or substance abuse treatment from an alcohol/substance abuse program that receives funds from the United States government, federal regulations may protect your treatment records from disclosure without your written authorization.
6. The Office of Mental Health's Requirements: Pederson-Krag Center, licensed by the New York State Office of Mental Health, is required by state and federal law to maintain the privacy of your health information. We are required to give you this notice of our legal duties and privacy practices with respect to the health information that Pederson-Krag Center collects and maintains about you. We are required to follow the terms of this notice.
This notice describes how your health information may be used or released. Release of your information outside of the boundaries of Pederson-Krag Center related treatment, payment, or operations, or as otherwise permitted by state or federal law, will be made only with your written authorization. You may revoke specific authorizations to release your health information at any time. If you revoke an authorization, we will no longer release your health information, except to the extent that we have already used or released that information with your original authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care we have provided to you.
We reserve the right to revise this notice. We reserve the right to make the revised notice effective for health information already on file about you as well as information we create or receive in the future. A current notice will be posted in the facility and we will provide a copy of our revised notice upon request. In addition, each time you are admitted to the facility for treatment, we will offer you a copy of the notice currently in effect.
7. To Report a Problem: If you believe your privacy rights have been violated, you may file a complaint with any or all of the agencies listed below. There will be no penalty or retaliation for filing a complaint:
The Pederson-Krag Center, Inc.
Office for Civil Rights
Secretary of Health and Human Services
Federal Center for Deaf and Hearing
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