NOTICE OF PRIVACY
PRACTICES
Hudson Valley Family Practice Associates, P.C.
This notice is provided
to you as a requirement of the Health Insurance Portability and
Accountability Act (HIPAA).
You will be asked to provide a signed acknowledgement of this notice for
your medical record. If you decline to acknowledge receipt of this notice we
will continue to provide treatment to you and will use your protected health
information for treatment, payment, and health care operations as necessary.
Protected Health Information (PHI) is health information that is
individually identifiable. It includes demographics, past and family medical
history, mental health conditions, and related health care services. We are
required by law to keep your PHI private.
Disclosure of PHI is permitted, by law, to you or someone acting on your
behalf, unless a mental health professional has determined that it would be
harmful to you. We must also disclose health information to the Department
of Health and Human Services (DHHS) at it's request.
We may also disclose your PHI to other physicians involved in your care,
nurses, pharmacists, or laboratories.
Your PHI may be disclosed to insurance companies or other parties that you
have designated to be responsible for payment of services rendered to you by
us. This includes the processes of determining insurance eligibility,
obtaining prior authorizations, utilization review, and billing.
We may call your name in our waiting room, leave a message on your answering
machine or send you a postcard reminding you of an appointment, and in these
cases we will omit diagnoses or medical terms in order to maintain your
privacy.
We may disclose your PHI to public health authorities for record keeping
(birth and death certificates, reporting child abuse, reporting of adverse
reactions to medications or vaccines, and notification of disease
exposures).
There are rare cases in which we may be required to disclose your health
information if requested, according to law, to government health oversight
agencies, the Food and Drug
Administration, courts of law for legal proceedings especially in
circumstances relating to crime, deaths suspected from criminal conduct,
crimes occurring on our premises, or medical emergencies resulting from
criminal conduct. Coroners or funeral directors may receive PHI.
We may also disclose PHI to Armed Force personnel to ensure proper execution
of a military mission or national security and intelligence activates.
Compliance with worker's compensation laws may require us to disclose your
PHI. If you are an inmate and we treat you we may disclose your information
to the institution from which you are at to ensure your health and safety or
the safety of others.
Parents or guardians may have access to their minor's health information.
You may agree or object to the use or disclosure of all or part of your PHI
including: release of information to employers, family members, life
insurance, disability or worker's compensation insurers, and trial lawyers.
You may inspect or obtain a copy of your PHI, with some exceptions,
(including psychotherapy notes).
Date:_______________
I,________________________________ have received, read and understand the
HIPAA Privacy notice given to me by Hudson Valley Family Practice
Associates, P.C.
Signature:____________________________________
Witness:______________________________________
4/14/03
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PATIENTS RIGHTS
Hudson Valley Family Practice Associates, P.C.
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You may ask us
not to use or disclose any part of your PHI for treatment, payment or
operations.
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You may request
that we communicate with you by alternate means to maintain
confidentiality.
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If you feel
that the information we have about you is incorrect you may request an
amendment (must be in writing).
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You have the
right to an accounting of disclosures we have made of your PHI beginning
April 14, 2003, and no more than 6 years from that date, except for
routine disclosure made in everyday treatment, payment and health care
operations.
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You may obtain
a copy of this privacy notice and it is posted in our website (www.hvfpa.com).
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There are more
specific laws that pertain to HIV-related information, mental health and
substance abuse information.
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Emancipated
minors may restrict the release of their PHI.
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You may address
any question or concerns that you have to our privacy officer at 2400 Rt.
9, Hudson, NY 12534.
4/14/03
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