HIPAA JOINT NOTICE OF PRIVACY PRACTICES

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

INTRODUCTION

This Joint Notice is being provided to you on behalf of NIS and the practitioners with clinical privileges that work at the Agency with respect to services provided at the Agency facilities (collectively referred to herein as “We” or “Our”). We understand that your medical information is private and confidential. Further, we are required by law to maintain the privacy of “protected health information.” “Protected health information” or “PHI” includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the Agency facilities. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from NIS HIPAA Privacy Officer or you can access it on our website at niskids.org. PERMITTED USES AND DISCLOSURES We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.

Treatment means the provision, coordination or management ofyour health care, including consultations between health careproviders relating to your care and referrals for health care from onehealth care provider to another. For example, a psychologisttreating you may need to know from your psychiatrist if you are onany medications.

Payment means the activities we undertake to obtain reimbursementfor the health care provided to you, including billing, collections,claims management, determinations of eligibility and coverage andother utilization review activities. For example, we may need toprovide PHI to your Third Party Payor to determine whether theproposed course of treatment will be covered or if necessary toobtain payment. Federal or state law may require us to obtain awritten release from you prior to disclosing certain speciallyprotected PHI for payment purposes, and we will ask you to sign arelease when necessary under applicable law.

Health care operations means the support functions of the Agency,related to treatment and payment, such as quality assuranceactivities, case management, receiving and responding to patientcomments and complaints, physician reviews, compliance programs,audits, business planning, development, management andadministrative activities. For example, we may use your PHI toevaluate the performance of our staff when caring for you. We mayalso combine PHI about many patients to decide what additionalservices we should offer, what services are not needed, and whethercertain new treatments are effective. We may also disclose PHI forreview and learning purposes. In addition, we may removeinformation that identifies you so that others can use the de-identified information to study health care and health care deliverywithout learning who you are.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We may also use your PHI in the following ways:

To provide appointment reminders for treatment or medical care.

To tell you about or recommend possible treatment alternatives orother health-related benefits and services that may be of interest toyou.

To your family or friends or any other individual identified by youto the extent directly related to such person’s involvement in yourcare or the payment for your care. We may use or disclose your PHIto notify, or assist in the notification of, a family member, a personalrepresentative, or another person responsible for your care, of yourlocation, general condition or death. If you are available, we willgive you an opportunity to object to these disclosures, and we willnot make these disclosures if you object. If you are not available,we will determine whether a disclosure to your family or friends isin your best interest, taking into account the circumstances andbased upon our professional judgment.

When permitted by law, we may coordinate our uses and disclosuresof PHI with public or private entities authorized by law or by charterto assist in disaster relief efforts.

We may contact you as part of our fundraising and marketing effortsas permitted by applicable law. You have the right to opt out ofreceiving such fundraising communications.

We may use or disclose your PHI for research purposes, subject tothe requirements of applicable law. For example, a research projectmay involve comparisons of the health and recovery of all patientswho received a particular medication. All research projects aresubject to a special approval process which balances research needswith a patient’s need for privacy. When required, we will obtain awritten authorization from you prior to using your healthinformation for research.

We will use or disclose PHI about you when required to do so byapplicable law.

Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.
SPECIAL SITUATIONS
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:

Organ and Tissue Donation. If you are an organ donor, we mayrelease PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the Armed Forces,we may release PHI about you as required by military commandauthorities. We may also release PHI about foreign militarypersonnel to the appropriate foreign military authority.

Worker’s Compensation. We may release PHI about you forprograms that provide benefits for work-related injuries or illnesses.

Public Health Activities. We may disclose PHI about you for publichealth activities, including disclosures:

to prevent or control disease, injury or disability;

to report births and deaths;

to report child abuse or neglect;

to persons subject to the jurisdiction of the Food and DrugAdministration (FDA) for activities related to the quality,safety, or effectiveness of FDA-regulated products or servicesand to report reactions to medications or problems withproducts;

to notify a person who may have been exposed to a disease ormay be at risk for contracting or spreading a disease orcondition;

to notify the appropriate government authority if we believethat an adult patient has been the victim of abuse, neglect ordomestic violence. We will only make this disclosure if thepatient agrees or when required or authorized by law.

Health Oversight Activities. We may disclose PHI to federal orstate agencies that oversee our activities (e.g., providing health care,seeking payment, and civil rights).

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute,we may disclose PHI subject to certain limitations.

Law Enforcement. We may release PHI if asked to do so by a lawenforcement official:

In response to a court order, warrant, summons or similarprocess;

To identify or locate a suspect, fugitive, material witness, ormissing person;

About the victim of a crime under certain limitedcircumstances;

About a death we believe may be the result of criminalconduct;

About criminal conduct on our premises; or

In emergency circumstances, to report a crime, the location ofthe crime or the victims, or the identity, description or locationof the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We mayrelease PHI to a coroner or medical examiner. We may also releasePHI about patients to funeral directors as necessary to carry out theirduties.

National Security and Intelligence Activities. We may release PHIabout you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.

Inmates. If you are an inmate of a correctional institution or underthe custody of a law enforcement official, we may release PHI aboutyou to the correctional institution or law enforcement official. Thisrelease would be necessary (1) to provide you with health care; (2)to protect your health and safety or the health and safety of others;or (3) for the safety and security of the correctional institution.

Serious Threats. As permitted by applicable law and standards ofethical conduct, we may use and disclose PHI if we, in good faith,believe that the use or disclosure is necessary to prevent or lessen aserious and imminent threat to the health or safety of a person or thepublic or is necessary for law enforcement authorities to identify orapprehend an individual.
Note: HIV-related information, genetic information, alcoholand/or substance abuse records, mental health records andother specially protected health information may enjoy certainspecial confidentiality protections under applicable state andfederal law. Any disclosures of these types of records will besubject to these special protections.

OTHER USES OF YOUR HEALTH INFORMATION
Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

YOUR RIGHTS

1. You have the right to request restrictions on our uses anddisclosures of PHI for treatment, payment and health care operations.However, we are not required to agree to your request. We are, however,required to comply with your request if it relates to a disclosure to yourhealth plan regarding health care items or services for which you havepaid the bill in full. To request a restriction, you may make your requestin writing to the Privacy Officer.

2. You have the right to reasonably request to receive confidentialcommunications of your PHI by alternative means or at alternativelocations. To make such a request, you may submit your request inwriting to the Privacy Officer.

3. You have the right to inspect and copy the PHI contained in ourAgency records, except:
(i) for psychotherapy notes, (i.e., notes that have beenrecorded by a mental health professionaldocumenting counseling sessions and have beenseparated from the rest of your medical record);
(ii) for information compiled in reasonable anticipationof, or for use in, a civil, criminal, or administrativeaction or proceeding;
(iii) for PHI involving laboratory tests when your accessis restricted by law;
(iv) if you are a prison inmate, and access wouldjeopardize your health, safety, security, custody, orrehabilitation or that of other inmates, any officer,employee, or other person at the correctionalinstitution or person responsible for transporting you;
(v) if we obtained or created PHI as part of a researchstudy, your access to the PHI may be restricted for aslong as the research is in progress, provided that youagreed to the temporary denial of access whenconsenting to participate in the research;
(vi) for PHI contained in records kept by a federal agencyor contractor when your access is restricted by law;and
(vii) for PHI obtained from someone other than us under apromise of confidentiality when the access requestedwould be reasonably likely to reveal the source of theinformation.
(viii) for other reasons permitted by applicable State or Federal law.

In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Medical Records Custodian. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.
We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

4. You have the right to request an amendment to your PHI butwe may deny your request for amendment, if we determine that the PHIor record that is the subject of the request:
(i) was not created by us, unless you provide areasonable basis to believe that the originator of PHIis no longer available to act on the requestedamendment;
(ii) is not part of your medical or billing records or otherrecords used to make decisions about you;
(iii) is not available for inspection as set forth above; or
(iv) is accurate and complete.
In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to Medical Record Custodian at our Agency, along with a description of the reason for your request.

5. You have the right to receive an accounting of disclosures ofPHI made by us to individuals or entities other than to you for the sixyears prior to your request, except for disclosures:
(i) to carry out treatment, payment and health careoperations as provided above;
(ii) incidental to a use or disclosure otherwise permittedor required by applicable law;
(iii) pursuant to your written authorization;
(iv) for the Agency’s directory or to persons involved inyour care or for other notification purposes asprovided by law;
(v) for national security or intelligence purposes asprovided by law;
(vi) to correctional institutions or law enforcementofficials as provided by law;
(vii) as part of a limited data set as provided by law.

To request an accounting of disclosures of your PHI, you must submit your request in writing to IGHL’s Privacy Officer. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.6. You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.COMPLAINTS If you believe that your privacy rights have been violated, you should immediately contact NIS HIPAA Privacy Officer at 631-878-8900. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services.CONTACT PERSON If you have any questions or would like further information about this notice, please contact NIS's Privacy Officer at
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT By signing below, I acknowledge that I have been provided with a copy of NIS Notice of Privacy Practices effective September 23, 2013. I have been advised of how my health or clinical information may be used or disclosed, and of my rights regarding the use and disclosure of this information.

________________________________________________ SIGNATURE of Service Recipient or Personal Representative

________________________________________________ PRINTED NAME of Service Recipient or Personal Representative

________________________________________________ Authority of Personal Representative

 

Return this page to: 221 North Sunrise Service Road   Manorville, NY 11949  Attention: Christina Smith, SDRANC

Effective 9/23/13; Revised 7/2023