HIPAA Privacy Policy

Notice of Privacy Practices version 04/24/2009

(Effective December 1, 2006)

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED BY THE

NY Pelvic and Minimally Invasive Gynecologic Surgery, P.C.,

AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION (PHI):

Understanding what is in your health record and how your health information is used will help you to ensure its accuracy, allow you to better understand who, what, when, where and why others may access your health information, and assist you in making more informed decisions when authorizing disclosure to others. When you visit us, we keep a record of your symptoms, examination, test results, diagnoses, treatment plan and other medical information. We also may obtain health records from other providers. In using and disclosing this protected health information (PHI), it is our objective to follow the Privacy Standards of the federal Health Insurance Portability and Accountability Act, 45 CFR Part 464. The law allows us to use and disclose PHI without specific authorization for sharing of information, when necessary and appropriate, with other health care providers, hospitals, pharmacies, therapists and all treating physicians, as necessary for your continued care. It also includes contacting you for appointment reminders and follow-up care. All other uses and disclosures require your specific authorization.

YOUR HEALTH INFORMATION RIGHTS ALLOW YOU TO:        

·         Request a restriction on the uses and disclosures of PHI as described in this notice, although we are not required to agree to the restriction your request. You should address your request in writing to the Privacy Officer. We will notify you within 30 days if we cannot agree to the restriction.

·         Obtain a paper copy of this Notice and upon written request, inspect and obtain a copy of your health record for a fee of $.75 per page and the actual cost of postage. Except that you are not entitled to access, or to obtain a copy of, psychotherapy notes and information compiled for legal proceedings.

·         Amend your health record by submitting a written request with the reasons supporting the request account for disclosures for treatment, payment, operations, or pursuant to authorization, among other exceptions.

·         Request in writing to the Privacy Officer that we communicate with you by a specific method and at a specific location.

We will typically communicate with you in person, or by letter, email, fax and/or telephone.

·         Revoke an authorization to use or disclose PHI at any time except where action has already been taken.

OUR RESPONSIBILITIES AS REQUIRED BY LAW:

·         Maintain the privacy of PHI and provide you with notice of our legal duties and privacy practices with respect to PHI.

·         Abide by the terms of the notice currently in effect. We have the right to change our notice of privacy practices and we will apply the change to your entire PHI, including information obtained prior to the change.

·         Post notice of any changes to our Privacy Policy in the lobby and make a copy available to you upon request.

·         Use or disclose your PHI only with your authorization except as described in this notice.

·         Follow the more stringent law in any circumstance where other state or federal law may further restrict the disclosure of your PHI.

FOR MORE INFORMATION OR TO REPORT A PROBLEM, CONTACT THE PRIVACY OFFICER AT:

NY Pelvic Pain and Minimally Invasive Gynecologic Surgery, P.C.,

Kenneth A. Levey MD MPH

90 Maiden Lane.

3^rd floor

New York, NY 10038

If you feel your rights have been violated you may file a complaint in writing with the Privacy Officer. If you are not satisfied with the resolution of the complaint, you may also file a complaint with the Secretary of Health and Human Services. Filing a complaint will not result in retaliation.

We may use or disclose your PHI for treatment, payment and operations, and for purposes described below:

We will use and exchange information obtained by a physician, nurse practitioner, nurse or other medical professionals, staff, trainees, and volunteers in our office to determine your best course of treatment. The information obtained from you or from other providers will become part of your medical records. We may also disclose your PHI to other outside treatment medical professionals and staff as deemed necessary for your care. For example, we may disclose your PHI to an outside doctor for referral. We will also provide your health care providers with copies of various reports to assist in your treatment.

PAYMENT:

We may send a bill to you or your insurance carrier. Also, the disbursement office may receive PHI as necessary to pay a claim. The information on or accompanying the bill may include information that indentifies you, as well as that portion of your PHI necessary to obtain payment.

HEALTH CARE OPERATIONS:

Members of the medical staff, trainees, medical students, a Risk or Quality improvement team, or similar internal personnel may use your information to assess the care and outcomes of your care in an effort to improve the quality of the healthcare and service we provide or for educational purposes. For example, an internal review team may review your medical records to determine the appropriateness of care. There may also be times in which our accountants, auditors, health information specialists or attorneys may review your PHI to meet their responsibilities.

OTHER USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION:

·         Business Associates: There are some services provided to our organization through contracts with business associates, such as laboratory and radiology services. We may disclose your health information to our business associates so that they can perform these services. We require that business associate to safeguard your information to your standards.

·         Notification:  We may disclose limited health information to friends and family members identified by you as being involved in your care or assisting you in payment.  We may also notify a family member, or another person responsible for your care, about your location and general condition.

·         Legally Required Disclosures & Public Health:  We may disclose PHI as required b y law, or in a variety of circumstances authorized by federal or state law. For example, we may disclose PHI to government officials to avert a serious threat to health or safety or for public health purposes, such as to prevent or control communicable disease (which may include notifying individuals that may have been exposed to the disease, although in such circumstance you will not be personally identified), federal or state health oversight agencies, child abuse or neglect, domestic violence,  to an employer to evaluate work related injuries, and to public officials to report births and deaths.

·         Law Enforcement & Subpoenas: We may disclose PHI to law enforcement such as limited information for identification and location purposes, or information regarding suspected of crime, including crimes committed on our premises. We may also disclose PHI to others as required by court or administrative order, or in response to a valid summons or subpoena.

·         Information Regarding Decedents: We may disclose health information regarding a deceased person to: 1) coroners and medical examiners to in identify cause of death or other duties, 2) funeral directors for their required duties and 3) to procurement organizations for the purposes of organ and tissue donation.

·         Research: We may also disclose PHI where the disclosure is solely for the purpose of designing a study, or where the disclosure concerns decedents, or an institutional review board of privacy board has determined that obtaining authorization is not feasible and protocols are in place to ensure the privacy of your health information. In all other situations, we may only disclose PHI for research purposes with your authorization.

·         Marketing and Fundraising: We may contact you with information about treatment alternatives or other related benefits and services that may be of interest to you. We may also contact you as part of a fundraising effort.

DISCLOSURES REQUIRING AUTHORIZATION:

The release of health information to other treating professionals will be made with written authorization from the patient, which you have the right to revoke at any time, except to extent we have already relied upon the authorization or in the event of an emergency.

ACKOWLEDGEMENT OF RECEIPT:

Federal law requires that we seek your acknowledgement of receipt of the Notice of Privacy Practices. Please sign below. I acknowledge that I have received this Notice of Privacy Practices with an effective date of December 1, 2006, and that I understand that if I have any questions regarding this Notice, I may contact the Privacy Officer.

Signature: _______________________________________________________Date:_______________

Printed  Name: _______________________________________________________________________

Signature of Parent/Guardian (specify which): ________________________________Date: __________