Notice of Privacy Practices
THIS 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.
What is Protected Health Information?
“Protected health information” or PHI is any information we create, receive, maintain or transmit that relates to your past, present or future health care or condition or treatment, and that identifies or can be used to identify you. This includes both your medical information and identification information, such as your address, workplace, social security number and other similar personal information. PHI in computers, such as billing data or images. It also includes other information such as information disclosed verbally.
Our Commitment to Your Privacy
The agency, Saratoga Center for the Family (SCFF) is required by law to maintain the privacy of your PHI and to provide you with notice of SCFF legal duties and privacy practices with respect to your PHI and are obligated to abide by the terms of this notice. SCFF is dedicated to maintaining the privacy of your PHI as part of providing professional care. The agency is required by law to keep your medical information private. This handout is a shorter version of the full, legally required NPP-Notice of Privacy Practices and you can ask for a printed copy of the longer version to read and refer to it for more information. Not all situations can be covered in this notice. You can request to speak to the SCFF Privacy Officer (see the end of this handout) with any questions. A copy of the Notice of Privacy Practices also appears on the agency website: www.saratogacff.org
SCFF is permitted by law to use and disclose your PHI without your written consent under certain circumstances. These include information SCFF collects about you to provide you with treatment, to arrange payment for services, and for other business activities called health care operations such as conducting quality assessments and improvement activities. Other uses and disclosures require your written permission. If you want SCFF to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form allowing this.
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of PHI for marketing purposes; (ii) contact made to you about appointment reminders or other health related benefits or services that may be of interest to you.
Disclosing Your Health Information without Your Consent
There are times when the law requires SCFF to use or share your or your child’s PHI but only to the minimum necessary to fulfill the lawful purpose. For example:
- Prevent or lessen a serious and imminent threat to the health or safety of an individual or the public
- To comply with a court order or court-ordered warrant, a subpoena or summons issued by a judicial officer, or a grand jury subpoena or other law enforcement investigations
- Health care providers can share patient information as necessary to identify, locate, and notify family members, guardians, or anyone else responsible for the individual's care of the individual's location, general condition, or death.
- For workers’ compensation and similar benefit programs.
- There may be other rare instances of PHI disclosure. They are described in the longer version of the SCFF Notice of Privacy Practices.
Your Rights Regarding Your Health Information
- You can ask us to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask us to call you at home, and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.
- You can ask us to permit communication or limit what we tell people involved in your care, such as family members and friends.
- You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records. The cost of copying records is .75 per page as allowed by law. Contact SCFF office at 518-587-8008 to obtain a copy of your medical records.
- You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket.
- You have the right to ask SCFF to amend PHI. SCFF must act on your request no later than 60 days after receipt of the written request and statement of the reason for the request. SCFF has the right to deny the request if (a) SCFF did not originate the information and (b) believes that the current information is accurate and complete. You will be provided with a written denial.
- SCFF will ensure reasonable safeguards of your PHI but cannot eliminate all risk of accidental disclosure and this does not constitute a violation of the Privacy Rule.
- You have the right to receive an accounting of disclosures of your or your child’s PHI.
- You have the right to a copy of this notice by electronic means (website or email) or you can request a paper copy. If we change this notice, we will post the new version in our waiting area, and you can obtain a copy of it from the privacy officer or SCFF receptionist. If SCFF changes this notice, the new version will posted in the waiting area in the Center location or at satellite office locations. SCFF will ask that you sign that you have received this document.
- You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our privacy officer and with the:
Secretary of the U.S. Department of Health and Human Services
U.S. Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Washington, D.C. 20201
Toll Free Call Center: 1-877-696-6775
All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. You may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact our privacy officer: Wende Tedesco, LCSW-R. Ms. Tedesco can be reached by phone at 518-587-8008 x 313 or by e-mail at email@example.com.
Consent to Use and Disclose Your Health Information
This form is an agreement between you, the client and Saratoga Center for the Family, When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have typed his or her name below, as the client.
When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health information” (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information.
If you do not complete this form agreeing to our privacy practices, we cannot treat you. In the future, we may change how we use and share your information, and so we may change our notice of privacy practices. If we do change it, you can get a copy from our website, http://www.saratogacff.org, or by calling us at 518-587-8008, or from our Clinical Director.
If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment,
or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing to our privacy officer. We will then stop using or sharing your PHI, but we may already have used or shared some of it, and we cannot change that.
By clicking the Read and Agree button, you are agreeing to let Saratoga Center for the Family use your PHI and to send it to others for the purposes outlined in the Consent to Use and Disclose Health Information. This also certifies that you have read or heard our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information.