Notice of Privacy Practice

Effective Date: April, 2003

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

We are required by law to protect the privacy of health information that may reveal your child’s identity, and to provide you with a copy of this notice which describes the health information privacy practices of St. Mary’s health care professionals who provide treatment or care for St. Mary’s residents, and affiliated health care providers that jointly perform payment activities and business operations with St. Mary’s. A copy of our current notice will always available in our reception area. You or your personal representative may also obtain a copy of this notice by requesting a copy from St. Mary’s staff.

If you have any questions about this notice or would like further information, please contact: Christian Martin, Privacy Officer at (718) 281-8587.

IMPORTANT SUMMARY INFORMATION

Requirement For Written Authorization. We will generally obtain your written authorization before using your child’s health information or sharing it with others outside St. Mary’s Healthcare System. You may also initiate the transfer of your records to another person by completing an authorization form. If you provide us with written authorization, you may revoke that authorization at any time, except to the extent that we have already relied upon it. To revoke an authorization, please contact Christian Martin, Privacy Officer at (718) 281-8587.

Exceptions To Requirement. There are some situations when we do not need your written authorization before using your child’s health information or sharing it with others. They are:

  • Exception For Treatment, Payment, And St. Mary’s Operations. We will only obtain your general consent one time to use and disclose your child’s health information to treat or care for your child’s condition, collect payment for that treatment or care, or run St. Mary’s normal business operations. For more information, see page 4 of this notice.
  • Exception For St. Mary’s Directory And Disclosure To Friends And Family Involved In Your Child’s Care. We will ask you whether you have any objection to including information about your child in St. Mary’s Directory or sharing information about your child’s health with your friends and family involved in your child’s care. For more information, see page 5 of this notice.
  • Exception In Emergencies Or Public Need. We may use or disclose your child’s health information in an emergency or for important public needs. For example, we may share your child’s information with public health officials at the New York State or city health departments who are authorized to investigate and control the spread of diseases. For more examples, see pages 6-8 of this notice.
  • Exception If Information Does Not Identify Your Child. We may use or disclose your child’s health information if we have removed any information that might reveal who your child is.

How To Access Your Child’s Health Information. You generally have the right to inspect and copy your child’s health information. For more information, please see page 8 of this notice.

How To Correct Your Child’s Health Information. You have the right to request that we amend your child’s health information if you believe it is inaccurate or incomplete. For more information, please see page 9 of this notice.

How To Keep Track Of The Ways Your Child’s Health Information Has Been Shared With Others. You have the right to receive a list from us, called an “accounting list,” which provides information about when and how we have disclosed your child’s health information to outside persons or organizations. Many routine disclosures we make will not be included on this list, but the list will identify non-routine disclosures of your information. For more information, please see page 9 of this notice.

How To Request Additional Privacy Protections. You have the right to request further restrictions on the way we use your child’s health information or share it with others. We are not required to agree to the restriction you request, but if we do, we will be bound by our agreement. For more information, please see page 10 of this notice.

How To Request More Confidential Communications. You have the right to request that we contact you in a way that is more confidential for you. We will try to accommodate all reasonable requests. For more information, please see page 10 of this notice.

How Someone May Act On Your Behalf. You have the right to name a personal representative who may act on your behalf to control the privacy of your child’s health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.

How To Learn About Special Protections For HIV, Alcohol and Substance Abuse, Mental Health And Genetic Information. Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you will be provided with separate notices explaining how the information will be protected. To request copies of these other notices now, please contact Christian Martin, Privacy Officer at (718) 281-8587.

How To Obtain A Copy Of This Notice. You have the right to a paper copy of this notice. You may request a paper copy at any time. To do so, please call Christian Martin, Privacy Officer at (718) 281-8587. You or your personal representative may also obtain a copy of this notice by requesting a copy from St. Mary’s staff.

How To Obtain A Copy Of Revised Notices. We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. The revised notice will apply to all of your child’s health information, and we will be required by law to abide by its terms. We will post any revised notice in St. Mary’s reception area. You or your personal representative will also be able to obtain your own copy of the revised notice by requesting a copy from St. Mary’s staff. The effective date of the notice will always be located in the top right corner of the first page.

How To File A Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact Christian Martin, Privacy Officer at (718) 281-8587. No one will retaliate or take action against you for filing a complaint.

WHAT HEALTH INFORMATION IS PROTECTED

We are committed to protecting the privacy of information we gather about your child while providing health-related services. Some examples of protected health information are:

  • information about your child’s health condition (such as a disease your child may have);
  • information about health care services your child has received or may receive in the future (such as an operation);
  • information about your child’s health care benefits under an insurance plan (such as whether a prescription is covered);
  • geographic information (such as where your child used to live or work);
  • demographic information (such as your child’s race, gender, ethnicity, or marital status);
  • unique numbers that may identify your child (such as social security number, phone number, or driver’s license number); and
  • other types of information that may identify who your child is.

HOW WE MAY USE AND DISCLOSE YOUR CHILD’S HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION

1. Treatment, Payment And St. Mary’s Business Operations

With your written consent, St. Mary’s staff and other health care professionals in the St. Mary’s Healthcare System may use your child’s health information or share it with others in order to provide your child with treatment or care, obtain payment for that treatment or care, and run the St. Mary’s normal business operations. Your child’s health information may also be shared with affiliated health care facilities and providers so that they may jointly perform certain payment activities and business operations along with St. Mary’s. Below are further examples of how your child’s information may be used with your consent.

Treatment. We may share your child’s health information with doctors or nurses at St. Mary’s who are involved in taking care of your child, and they may in turn use that information to diagnose or treat your child. A doctor at St. Mary’s may share your child’s health information with another doctor inside St. Mary’s, or with a doctor at another health care facility, to determine how to diagnose or treat your child. Your child’s doctor may also share health information with another doctor to whom your child has been referred for further health care.

Payment. We may use your child’s health information or share it with others so that we obtain payment for your child’s health care services. For example, we may share information about your child with your child’s health insurance company in order to obtain reimbursement for treatment or care we have provided to your child. In some cases, we may share information about your child with your child’s health insurance company to determine whether it will cover your child’s future treatment or care.

Business Operations. We may use your child’s health information or share it with others in order to conduct our normal business operations. For example, we may use your child’s health information to evaluate the performance of our staff in caring for your child, or to educate our staff on how to improve the care they provide for your child. We may also share your child’s health information with another company that performs business services for us, such as a billing company. If so, we will have a written contract to ensure that this company also protects the privacy of your child’s health information.

Treatment Alternatives, Benefits And Services. We may use your child’s health information when we contact you in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.

Fundraising. We may use your child’s information when deciding whether to contact you or your personal representative to raise money to help us operate. We may also share this information with a charitable foundation that will contact you or your personal representative to raise money on our behalf. If you do not want to be contacted for these fundraising efforts, please contact Christian Martin, Privacy Officer at (718) 281-8587.

We can do all of these things if you have signed a one-time consent form. Once you sign this consent form, it will be in effect indefinitely until you revoke your consent. You may revoke your consent at any time, except to the extent that we have already relied upon it. For example, if we provide you with treatment or care before you revoke your consent, we may still share your child’s health information with your insurance company in order to obtain payment for that treatment or care. To revoke your consent, please contact Christian Martin, Privacy Officer at (718) 281-8587.

2. St. Mary’s Directory/Friends And Family

We may use your child’s health information in St. Mary’s Directory, or share it with friends and family involved in your care, without your written authorization or consent. We will always give you an opportunity to object. We will follow your wishes unless we are required by law to do otherwise.

St. Mary’s Directory. If you do not object, we will include your child’s name, your location in our facility and your religious affiliation in St. Mary’s Directory while your child is a resident in the St. Mary’s. This directory information, except for your child’s religious affiliation, may be released to people who ask for you by name. Your child’s religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if he or she doesn’t ask for your child by name.

Friends And Family Involved In Your Child’s Care. If you do not object, we may share your child’s health information with a family member, relative, or close personal friend who is involved in your child’s care or payment for that care. We may also notify a family member, personal representative or another person responsible for your child’s care about your child’s location and general condition here at the St. Mary’s, or about the unfortunate event of your child’s death. In some cases, we may need to share your child’s information with a disaster relief organization that will help us notify these persons.

3. Emergencies Or Public Need

We may use your child’s health information, and share it with others, in order to treat your child in an emergency or to meet important public needs. We will not be required to obtain your written authorization, consent or any other type of permission before using or disclosing your child’s information for these reasons.

Emergencies. We may use or disclose your child’s health information if your child needs emergency treatment or if we are required by law to treat your child but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat your child.

Communication Barriers. We may use and disclose your child’s health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat your child if we could communicate with you.

As Required By Law. We may use or disclose your child’s health information if we are required by law to do so. We also will notify you of these uses and disclosures if notice is required by law.

Public Health Activities. We may disclose your child’s health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your child’s health information with government officials that are responsible for controlling disease, injury or disability. We may also disclose your child’s health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so.

Victims Of Abuse, Neglect Or Domestic Violence. We may release your child’s health information to a public health authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we may report your child’s information to government officials if we reasonably believe that your child has been a victim of abuse, neglect or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your child’s health information to government agencies authorized to conduct audits, investigations, and inspections of our facility. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair And Recall. We may disclose your child’s health information to a person or company that is required by the Food and Drug Administration to: (1) report or track product defects or problems; (2) repair, replace, or recall defective or dangerous products; or (3) monitor the performance of a product after it has been approved for use by the general public.

Lawsuits And Disputes. We may disclose your child’s health information if we are ordered to do so by a court that is handling a lawsuit or other dispute.

Law Enforcement. We may disclose your child’s health information to law enforcement officials for the following reasons:

  • To comply with court orders or laws that we are required to follow;
  • To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
  • If your child has been the victim of a crime and we determine that: (1) we have been unable to obtain your consent because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
  • If we suspect that your child’s death resulted from criminal conduct;
  • If necessary to report a crime that occurred on our property; or

To Avert A Serious Threat To Health Or Safety. We may use your child’s health information or share it with others when necessary to prevent a serious threat to your child’s health or safety, or the health or safety of another person or the public. In such cases, we will only share your child’s information with someone able to help prevent the threat. We may also disclose your child’s health information to law enforcement officers if your child tells us that he/she participated in a violent crime that may have caused serious physical harm to another person (unless your child admitted that fact while in counseling), or if we determine that your child escaped from lawful custody (such as a prison or mental health institution).

National Security And Intelligence Activities Or Protective Services. We may disclose your child’s health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Inmates and Correctional Institutions. If your child later becomes incarcerated at a correctional institution or detained by a law enforcement officer, we may disclose your child’s health information to the prison officers or law enforcement officers if necessary to provide your child with health care, or to maintain safety, security and good order at the place where your child is confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers’ Compensation. We may disclose your child’s health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners And Funeral Directors. In the unfortunate event of your child’s death, we may disclose your child’s health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.

Organ And Tissue Donation. In the unfortunate event of your child’s death, we may disclose your child’s health information to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your child’s health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your child’s health information without your authorization if we obtain approval through a special process to ensure that research without your authorization poses minimal risk to your child’s privacy. Under no circumstances, however, would we allow researchers to use your child’s name or identity publicly. We may also release your child’s health information without your authorization to people who are preparing a future research project, so long as any information identifying your child does not leave our facility. In the unfortunate event of your child’s death, we may share your child’s health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies your child.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR CHILD’S HEALTH INFORMATION

We want you to know that you have the following rights to access and control your child’s health information. These rights are important because they will help you make sure that the health information we have about your child is accurate. They may also help you control the way we use your child’s information and share it with others, or the way we communicate with you about your child’s medical matters.

1. Right To Inspect And Copy Records

You have the right to inspect and obtain a copy of any of your child’s health information that may be used to make decisions about your child and your child’s treatment for as long as we maintain this information in our records. This includes medical and billing records. To inspect or obtain a copy of your child’s health information, please submit your request to Christian Martin, Privacy Officer (718) 281-8587. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. The standard fee is $0.75 per page and must generally be paid before or at the time we give the copies to you. We will respond to your request for inspection of records within twenty-four hours. We ordinarily will respond to requests for copies within two working days.

Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your child’s information. If we do, we will provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.

2. Right To Amend Records

If you believe that the health information we have about your child is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. To request an amendment, please contact Christian Martin, Privacy Officer (718) 281-8587. Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your child’s records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

3. Right To An Accounting Of Disclosures

After April 14, 2003, you have a right to request an “accounting of disclosures” which is a list with information about how we have shared your child’s information with others. An accounting list, however, will not include:

  • Disclosures we made to you;
  • Disclosures we made in order to provide your child with treatment or care, obtain payment for that treatment or care, or conduct our normal business operations;
  • Disclosures made in the facility directory;
  • Disclosures made to your friends and family involved in your child’s care;
  • Disclosures made to federal officials for national security and intelligence activities;
  • Disclosures about inmates to correctional institutions or law enforcement officers; or
  • Disclosures made before April 14, 2003.

To request this list, please contact Christian Martin, Privacy Officer at (718) 281-8587. Your request must state a time period for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2004 and January 1, 2005. You have a right to one list within every 12-month period for free. However, we may charge you for the cost of providing any additional lists in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.

Ordinarily we will respond to your request for an accounting list within 60 days. If we need additional time to prepare the accounting list you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting list. In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.

4. Right To Request Additional Privacy Protections

You have the right to request that we further restrict the way we use and disclose your child’s health information to provide you with treatment or care, collect payment for that treatment or care, or run St. Mary’s normal business operations. You may also request that we limit how we disclose information about your child to family or friends involved in your child’s care. For example, you could request that we not disclose information about a surgery your child had. To request restrictions, please contact Christian Martin, Privacy Officer at (718) 281-8587. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

5. Right To Request Confidential Communications

You have the right to request that we communicate with you or your personal representative about your medical matters in a more confidential way. To request more confidential communications, please contact Christian Martin, Privacy Officer at (718) 281-8587. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how you or your personal representative wish to be contacted, and how payment for your health care will be handled if we communicate with your personal representative through this alternative method or location.

FOR FURTHER INFORMATION, PLEASE CONTACT:

CHRISTIAN MARTIN, PRIVACY OFFICER
29-01 216TH STREET
BAYSIDE, NY 11803
(718) 281-8587