PORT JEFFERSON HEALTH CARE FACILITY

 

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION.

Text Box: Port Jefferson Health Care Facility is committed to providing residents/patients with an optimal level of quality health care services and education with compassion, respect, and dignity. We place tremendous value on protecting the privacy and integrity of your health information. We want you to have a clear understanding of how we use and disclose that information and your rights regarding your protected health information, frequently called PHI.PLEASE REVIEW IT CAREFULLY

 

Port Jefferson Health Care Facility is required to abide by this Privacy Notice.   We may modify the terms of this notice, and the revised notice will be effective for all protected health information in our possession at the time of change and any information created or received after. You may request a copy of any revised notice by contacting our Social Work Department.

 

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI)

 

The Facility uses PHI about you for treatment, payment, and operational purposes.  We are not required to obtain your authorization for those uses. We may also use or disclose your PHI without your authorization for public health reasons, auditing purposes, emergencies, and where permitted or required by law such as government oversight and licensing, court subpoena, etc.

 

Treatment

We may disclose your protected health information to doctors, nurses, aides, and staff directly involved with providing care or overseeing the services provided to you.  We may also disclose your protected health information to outside entities performing other services relating to your treatment; such as pharmacies, diagnostic laboratories, home health agencies, and durable medical equipment companies, etc.

 

Payment

We may provide information to business personnel, data entry staff, and others involved in the billing and collection of payment for services we provide to you.   Additionally, we may disclose PHI to your insurance company, health plan or another third party in the process of billing and collecting payment. 

 

Healthcare Operations

We may provide information to our admissions staff, medical records staff, data entry operators, purchasing staff, and others who compile patient charts, audit charts, request records, schedule ancillary services, and order equipment in the process of providing for your care and treatment. Additionally, we may provide information on a need-to-know basis to business associates and others who provide accounting services, auditing services, legal counsel, education and training, and services specific to internal operations.

 

 

 

Your Written Authorization

For uses and disclosures beyond treatment, payment, and operations, we are required to have your written authorization, except as permitted by law (see below). If you wish us to release records to individuals or entities not legally entitled to your records, including a relative, attorney, or a health care provider not presently involved in your care, you must provide us with written authorization each time you wish us to release records.. You may obtain appropriate authorization forms from our Medical Records Department. If we receive a request for your records from your attorney, relative, or others not legally entitled to your protected health information we must obtain your signed authorization to release the records. We must obtain your written authorization for marketing or before permitting a researcher to use your information. You have the right to revoke authorization in writing at any time by completing a Revocation Form available from the Medical Records Department or you may send a signed, dated letter to the Medical Records Department at the address listed on the last page, describing what you wish to revoke. If you revoke your authorization it will not affect any use or disclosure made while your authorization was in effect.

 

Separate and specific authorization is required to disclose confidential HIV related information (NY State Public Health Law 2786) and Psychiatry or Psychology consults and notes (NY State Mental Hygiene Law, Sec. 33.13:c). HIV related information and mental health records are not subject to disclosure by subpoena. You may contact the Medical Records Department to obtain further information about patient confidentiality in these related areas or to obtain authorization forms.

 

Uses or Disclosures Based On Your Verbal Agreement

 

1. Facility Directory

We may use or disclose your name, room number, and facility phone number in our facility directory. This information may be disclosed to your visitors or callers when they ask for you by name. You may request to have this information remain confidential and based on your verbal request we will not give out this information to visitors or callers except for treatment, payment, and health care operations and where required by law.

 

2. Facility Recreational Activities

You may provide us with verbal permission if you wish to have your name or birthday announced in facility activity calendars or at events however, you are under no obligation to do so. 

 

3. Information Disclosed To Family Members, Friends or Others Involved in Your Care

With your verbal permission we may disclose your protected health information on a need to know basis to those family members and/or friends who you have identified as being directly involved in your care or who assist with securing payment for your care.  We may disclose information to those individuals you permit to be present when staff is discussing treatment, patient education, and discharge planning with you. 

 

Uses and Disclosures That Do Not Require Your Consent or Authorization

 

1.  Required by Law

We may use or disclose your health information when a federal, state, or local law requires that we report information about communicable diseases, suspected abuse, neglect, or domestic violence, adverse reactions to medications or injury from a health care product, or in response to a court order or subpoena.

 

 

 

 

2. Health Oversight Activities

We may disclose your protected health information to the Federal or State Department of Health inspecting our facility or to other government agencies responsible for health oversight or patient protection and advocacy.

 

3. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Agencies

We may disclose information to a coroner or medical examiner as requested.  We may disclose information to a funeral director for purposes of carrying out your wishes or the director’s duties. If you are an organ donor, we may disclose your protected health information to the organization(s) responsible for facilitating your donation.

 

4. To Avert a Serious Threat to Health or Safety

We may disclose your protected health information to avoid a serious threat to your health or safety or to the health or safety of others.  When such disclosure is necessary, information will only be released to those law enforcement agencies that have the ability or authority to prevent or lessen the threat of harm.

 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

 

You have the following rights concerning use or disclosure of your protected health information

 

1.     To Request Restrictions on Uses and Disclosures of Protected Health Information:

 

You may request that we limit how we use or disclose protected health information for treatment, payment, health care operations, or to your Designated Representative or Sponsor.  Should you wish to request a restriction you must submit such request in writing to the Director of Medical Records  or complete the Request To Restrict The Use and Disclosure of Protected Health Information form available from the Medical Records Department. The name, address, and telephone number of the person to whom the request is to be submitted is listed on the last page of this document.  We are not required to agree to your restriction request.  However, should we agree, we will comply with your request unless the information you wish to restrict is needed to provide emergency care or treatment to you.

 

2.     To Inspect and Receive Copies of Your Medical and Billing Records:

 

·       You have the right upon oral or written request to inspect your clinical records and billing records within 24 hours (excluding weekends and holidays). 

·       You upon written request and 2 working days advance notice, have the right to purchase photocopies of the records generated by the Facility, while a patient in the Facility, at a cost of 75 cents per page. 

 

3.     To Request Amendment of Records:

 

      You have the right to request that we amend the record if you have reason to believe it is

       incorrect or incomplete. Your request must be submitted to the Medical Record Department in

       writing stating which portion of the record you wish to have amended and the reason(s) you wish to

       have the record amended. You may obtain a Request For Amendment Form from our Medical

       Record Department listed on the last page of this Notice.  We will respond within sixty (60) days of

       receiving the written request.  If we approve your request, we will make such amendments and

       notify those with a need to know of such amendment.  We may deny your request because;

 

·       your request is not submitted in writing

·       your written request does not contain a reason(s) that supports your request

·       the information was not created by us

·       the request does not concern protected health information kept by or for our facility

·       we have reviewed the information and believe it to be accurate or complete

 

     If your request is denied, we will provide you with a written notification of the reason(s) we denied

     your request.  You have the right to have your request, the denial, and any written response you made

     relative to the information attached to your health information.  Request For Amendment Forms may

     be obtained from the Medical Records Department listed on the last page of this document.

 

4.  Right to Request an Accounting of Disclosures of Protected Health Information

 

You have the right to request that we provide you with a list of when, to whom, for what purpose, and what content of your PHI we have released over a specified period of time.  The accounting will not include disclosures or releases made for treatment, payment, health care operations, or those made pursuant to your written or verbal authorization.

 

Your request must be submitted to us in writing.  It may not include releases dating back to more than 6 years prior to your request.  It may not include releases prior to April 14, 2003. We will respond to your request within 60 days of our receipt of your written request.  Should additional time be needed we will notify you of such extension.  In no case will such extension exceed 30 days.  The first accounting requested in a 12 month period will be free.  We will charge a reasonable fee for additional requests made during the same 12 month period. 

 

5. Right to Confidential Communications

 

You have the right to request that we communicate with you confidentially and by alternate means.  For example, if you wish bills to be sent other than to your home address you may contact your social worker to facilitate your request.

 

 

 

How to File a Complaint About Our Privacy Practices

 

If you have reason to believe that your privacy rights have been violated or you have additional questions or concerns you may contact the Corporate Compliance Officer at ext. 209.  If you wish to file a complaint you may do so with the Corporate Compliance Officer or the U.S. Department of Health & Human Services Office for Civil Rights within 180 days from the date of the incident of complaint. Contact information is listed on the last page.  Complaints may be filed without fear of retaliation in any form.

 

 

Effective Date:  April 11, 2003

 

 

 

 

 

 

 

 

 

 

Complaints

Kathleen Peets

Corporate Compliance Officer                           

Pt Jefferson Health Care Facility

Dark Hollow Rd.

Pt. Jefferson, N. Y. 11777

(631) 473-5400 x 209

 

 

 

Office for Civil Rights

U. S. Dept. of Health & Human Services

Jacob Javits Federal Bldg

26 Federal Plaza, Suite 3312

New York,  N. Y.  10278

(212) 264-3313

 

 

 

  

Medical Records and Facility Forms

Medical Records Department

Pt. Jefferson Health Care Facility

Dark Hollow Rd.

Pt. Jefferson, N. Y.  11777

(631) 473-5400 x 256