Acknowledgement of Privacy Procedures

NOTICE OF PRIVACY PRACTICES This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment and / or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information that may identify you and 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 maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy procedures with respect to your protected health information. Staten Island Physician Practice (SIPP) is committed to, and required by law to maintain the privacy of all PHI of our patients and adhere to the policies and procedures that are currently in place. Please review this carefully. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT PATIENT CONSENT: All other releases of information will be accompanied by an authorization filled out by the patient or a representative TREATMENT: We will use your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. HEALTHCARE OPERATIONS: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. EXAMPLES: These are examples of how we may use your protected health information and is not meant to be an all encompassing list. • Facilitate insurance reimbursement. • Referral to another provider for continuation of care. • Pre-authorization for hospital admission. • Address patients by name when calling from the waiting room. • Contact you through different forms of communication for marketing purposes. • Notify your employer under limited circumstances related to workplace injury, illness or medical surveillance. • Adhere to Federal and New York State Laws. YOUR RIGHTS: The following are your rights with respect to your protected health information. • PHI will be retained for a minimum of seven years for adults or the amount of years until a minor reaches the age of eighteen years plus seven years after an individual’s insurance is either terminated or they have been inactive with SIPP for one calendar year. • You have the right to obtain a copy of this notice, upon request. • You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. (This includes requests for removal from SIPP appointment reminders or marketing calls.) A form to request a restriction can be found in all provider service areas. • You have the right to receive confidential communication from Staten Island Physician Practice by alternative means or at an alternative location. In order to do so, contact the HIPAA Privacy Officer or the Patient Advocate. • You have a right to inspect and / or receive a copy of your PHI in Staten Island Physician Practice’s Designated Record Set (health records). • All information requested must be accompanied by completing an Authorization to release this information. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. • You have the right to receive an accounting of certain disclosures we have made, if any of your protected health information that you did not authorize. • You have the right to request your physician amend your protected health information. If your request is denied, you have the right to file a statement of disagreement with us. We reserve the right to change the terms of this notice. We will do so by adding the amended date to this published form. If you believe your privacy has been violated by Staten Island Physician Practice, you may complain to us by contacting the HIPAA Privacy Officer at (718) 816 - 3707 or to the Secretary of Health and Human Services at www.hhs.gov We are required by law to maintain all privacy notice acknowledgements for a minimum of 6 years. This notice was published and becomes effective April 14, 2003.