HIPPA Privacy Notice

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EMERGENCY ONE
Urgent Care and Diagnostic Center

40 Hurley Avenue -Suite 4 Kingston, NY 12401 (845) 338 5600

4250 Albany Post Road- Suite 1, Hyde Park, NY 12538 (845) 229 2602

306 Windsor Highway, New Windsor, NY 12553 (845) 787-1400

NOTICE OF PRIVACY PRACTICES

Effective April 14, 2003

In compliance with the Final Rule

Compliance date September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

THIS NOTICE OF PRIVACY PRACTICES IS PROVIDED TO YOU, AS A REQUIREMENT OF THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA.) THIS NOTIEC OF PRIVACY PRACTICES DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) WITH WHOM THAT INFORMAITON MAY BE SHARED AND THE SAFEGUARDS WE HAVE IN PLACE TO PROTECT IT. THIS NOTICE ALSO DESCRIBES YOUR RIGHTS TO ACCESS AND AMEND YOUR PHI. YOU HAVE THE RIGHT TO APPROVE OR REFUSE THE RELEASE OF SPECIFIC INFROMATION OUTSIDE OF EMERGENCY ONE, EXCEPT WHEN THE RELEASE IS REQUIRED OR AUTHORIZED BY LAW OR REGULATION.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE

You will be asked to provide a signed acknowledgment of the receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide you treatment, and will use and disclose your PHI for treatment, payment and health care operations when necessary.

OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION (PHI)

Protected Health Information” (PHI) is individually identifiable health information. This information includes demographics (for example- age, address), and related to your past, present and future physical and mental health or condition and related health care services. Emergency One is required be law to do the following:

We reserve the right to change this notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. You may request and receive a copy of this Notice of Privacy Practices or by accessing our website at www.eonekingston.com.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

Following are examples of permitted uses and disclosures or you PHI. These examples are not exhaustive.

Required Uses and Disclosures

By law, we must disclose your information to you unless it has been determined by a health care professional that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Heath and Human Services (DHHS) for investigation or determinations or our compliance with laws on the protection of your health information.

Treatment

We will use and disclose your PHI to provide, coordinate or manage you health care and any related service. This includes the coordination or management of your health care with a third party. For example, we may disclose your PHI from time to time to another physician or health care provider (for example- a specialist, pharmacist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. This includes pharmacists who may who may be provided information on other drugs you have been prescribed to identify potential interactions.

In emergencies, we will use and disclose your PHI to provide the treatment you require.

Payment

Your PHI will be used, as needed, to obtain payment for your health services. This may include certain activities we may need to undertake before your health care insurer approves or pays for the health care services provided to you recommended to you, such as determining eligibility or coverage for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for the procedure at a particular facility.

Health Care Operations

We may use or disclose, as needed, your PHI to support our daily activities related to providing health care. These activities include, but are not limited to billing, collection, quality assessment activates, investigations, oversight or staff performance reviews, licensing, communications about a produce of service and conducting or arranging for other heath care related activities. For example, we may disclose your PHI to a billing agency in order to prepare claims for reimbursement for the services we provide you. We may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. For example, we will contact you at your home telephone number to remind you of your next appointment.

We will share your PHI with other persons and entities that perform various activities (for example, a transcription service) for Emergency One. These business associates of Emergency One will also be required to protect your health information.

We may use or disclose your PHI, as necessary, to provide you with information about your treatment alternatives or other health related benefits and services that might interest you. For example, your name and address may be used to send you a newsletter about Emergency One and the services we offer. We may also send you information about products and services that we believe might benefit you.

Required by Law

We may use or disclose your PHI if law or regulation requires the use or disclosure.

Public Health

We may disclose your PHI to a public health authority who is permitted by lay to collect or receive the information. The disclosure may be necessary to do the following:

Communicable Diseases

We may disclose your PHI, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight

We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil right laws.

Food and Drug Administration

We may disclose your protected health information to a person or company required by the Food and Drug Administration to do the following:

Legal Proceedings

We may disclose PHI during any judicial or administrative proceeding, in response to a court order or administrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process.

Law Enforcement

We may disclose PHI for law enforcement purposes, including the following:

Coroners, Funeral Director, and Organ Donations

We may disclose PHI to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by the law. PHI may be used and disclosed for cadaveric organ, eye or tissue donation.

Research

We may disclose your PHI to researchers when authorized by law, for example, if their research has been approved by an institutional review board that had reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Criminal Activity

Under applicable federal and state laws, we may disclose your PHI if we believe that its use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security

When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities believed necessary by appropriate military command authorities to ensure the proper execution of the military mission including the determination of fitness for duty, or (2) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or others.

Workers’ Compensation

We may disclose your PHI to comply with workers’ compensation laws and other similar legally established programs.

Parental Access

State laws concerning minors permit or require certain disclosure or PHI to parents, guardians, and persons acting in similar legal status. We will act consistently with the laws of New York and make disclosures following such laws.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI) REQUIRING YOUR PERMISSION:

In some circumstances, you have the opportunity to agree or object to the use or disclosure if all or part if your PHI. Following are examples in which your agreement or objection is required:

Individuals Involved in your Health Care

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. We may also give information to someone who helps pay for your health care. Additionally, we may use or disclose PHI to notify or assist in notifying a family members, personal representative, or any other person who is responsible for your care, of location, general condition, or death. Finally, we may use or disclose you PHI to am authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.

Your Rights Regarding Your Health Information

You may exercise the following rights by submitting a written request to our Privacy Officer. Our Privacy Officer will guide you in pursuing these options. Please be aware that Emergency One may deny your request; however, you may seek a review of the denial.

Right to Inspect and Copy

You may inspect and obtain a copy of your PHI that is contained in a “designated record set” for as long as we maintain the PHI. A designated record set contains medical and billing records and any other records that Emergency One uses for making decisions about you.

This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, a criminal, or administrative action or proceeding; and PHI that is subject to a law that prohibits access to PHI.

Right to Request Restrictions

You may ask us not to use or disclose any part of your PHI for treatment, payment, or health care operations. Your request must be made in writing to our Privacy Officer. We will only disclose the following with your authorization: most uses and disclosures of psychotherapy notes recorded by Emergency One, uses and disclosures of PHI for marketing purposes, including subsidized treatment communications, disclosure that constitute a sale of PHI, and other uses and disclosures not described herein. In your request, you must tell us (1) what information you want restricted; (2) whether you want to restrict our use or disclosure, or both; (3) to whom you want the restriction to apply, for example, restrictions to your spouse; and (4) an expiration date.

If we believe that the restriction is not in the best interest of either party, or that we cannot reasonably accommodate the request, we are not required to agree to your request. If the restriction is mutually agreed upon, we will not use or disclose your PHI in violation of the restriction, unless it is needed to provide emergency treatment.

You may revoke a previously agreed upon restriction, at any time, in writing.

Right to Request Confidential Communications

If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your PHI as long as we maintain this information. While we will accept an amendment, we are not required to agree with the amendment.

Right to an Accounting of Disclosures

You may request that we provide you with am accounting of the disclosure we have made to your PHI. This right applies to disclosures made for purposes other than treatment, payment, or health care operations as described in the Notice of Privacy Practices. The disclosure must have been made after April 14, 2003, and no more that 6 years from the date of request. This right excludes disclosures made to you directly, to others pursuant to an authorization from you, to family members or friends involved in you care, or for notification purposes. The right to receive this information is subject to exceptions, restrictions, and limitations as described earlier in this Notice.

Right to Obtain a Copy of this Notice

You may obtain a paper copy of this notice from us by requesting one, or view it or download it electronically at www.eonekingston.com.

Special Protections

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). There are several other privacy laws that also apply to HIV- related information, mental health information, and substance abuse information. These laws have not been superseded and have been taken into consideration in developing our policies and this notice of how we will use and disclose you PHI. Emergency One is required to notify you of any breach of your unsecured PHI.

Complaints

If you believe these privacy rights have been violated, you may file a written complaint with our Privacy Officer or the Department of Health and Human Services. No retaliation will occur against you for filing a complaint.

Contact Information

Our Privacy Officer is our Office Manager and can be contacted by calling 845-338-5600. You may contact our Privacy Officer for further information about our complaint process, or for further explanation of this Notice of Privacy Practices.

This Notice is Effective in its Entirety as of April 14, 2003.

In compliance with the Final Rule

Compliance date September 23, 2013