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.

The Hamilton County Public Health Nursing Services is required by law to maintain the privacy of your medical information and to give you this notice of legal duties and privacy practices with respect to medical information about you. This notice may be revised at any time. Any revisions will be effective for past, present or future medical information we have about you. The Hamilton County Public Health Nursing Service is required to follow the terms of the most current notice, to post it in all sites where physical services are delivered, to offer you an updated Notice any time the contents of Notice is changed while you are still receiving care or services. In addition, you will be offered a Notice each time you receive services or are admitted to the Hamilton County Public Health Nursing Service, you will receive a copy of the notice.

ALL EMPLOYED AND CONTRACT STAFF WILL FOLLOW THIS NOTICE

Uses and Disclosures of Health Information:

For Treatment: To your doctor and for referrals, appointment reminders and coordination with programs that may be involved in your care such as friend or family member, labs, pharmacy, medical equipment provider, or meals on wheels.

For Payment: To the insurance company. Copies of notes related to treatment and services you received may be required to accompany the bill.

For Health Care Operations: To run the Agency and to assess patient care such as reviewing our treatment and services and to evaluate the performance of staff in caring for you.

* If Applicable- may contact the individual for appointment reminders or to give information regarding treatment alternatives, may contact individual to raise funds for the covered entity, and if group health plan may disclose protected health information to the sponsor of the plan.

Special Situations - PHI may be released without your consent or authorization:

As Required by Law and to avert serious threat to health and safety: In response to court order, subpoena, warrant, summons or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; In emergency circumstances to report details of a crime, suspected crime, or about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; National Security, intelligence activities and protective services for the President or other officials; etc..

Public Health Risks - To prevent or control disease, injury or disability, to report births and deaths, to report child abuse or neglect or domestic violence when required or authorized by law, in the event of a disaster, etc..

Health Oversight Activities – including audits, investigations, inspections, and licensure activities as required by State or Federal Mandate.

Coroners, Medical Examiners and Funeral Directors – For identification purposes, to determine cause of death or as necessary to carry out their duties.

Organ and Tissue Donation - If a donor, to an organization that handles organ procurement.

Research

Military and Veterans - As required by military command authorities.

Workers compensation- as required to comply with laws relating to workers compensation.

(Exceptions to Release without consent – We will follow the provisions of 42 CFR Part 2, which severely restricts the release of protected health information if the records are from substance abuse treatment. There are also special rules about releasing HIV/AIDS/STD services. The Department must make special efforts to protect the names of people who receive these services)

Other Uses of Medical Information not covered by this notice or applicable law will be made only with your written permission. Permission may be revoked by you in writing, at any time. Please understand that we are unable to take back any disclosures we have already made with your permission.

You have the right to:

· Request a restriction on the medical information we use or disclose about you. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. A request for restrictions must be made in writing to the Director of Patient Services and must specify the information to be restricted, if restriction is for use and/or disclosure, and who the restriction applies to.

· Request Confidential Communications-You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Written request must be submitted to the Privacy Officer/designee. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

· Inspect and copy medical information (usually medical and billing records) that may be used to make decisions about your care. Request must be in writing to the attention of the Privacy Official. A fee of 75 cents per page may be charged for the cost of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. A denial will be issued in writing with instructions on how to request a review of the denial.

· Request an amendment if you feel that medical information we have about you is incorrect or incomplete. You have the right to request an amendment for as long as the information is kept by or for the Agency. The written request must be submitted to Privacy Officer/designee with a reason that supports your request. Your request for an amendment may be denied. You will receive the denial in writing with an explanation and instructions on how to appeal the denial decision.

· Receive an accounting of disclosures for reasons other than treatment, payment or health care operations. Requests must be in writing to the Privacy Officer/designee and state a time period which may not be longer than six years or include dates prior to April 14, 2003. The list will be a paper copy and the first list you request within a 12 month period will be free. Additional lists may incur a cost. You will be notified of the amount involved to give you the opportunity to withdraw or modify your request before any costs are incurred.

· Receive a paper copy of this notice upon request.

Complaints:

If you believe that your privacy rights have been violated, you have the right to complain without fear of reprisal or retaliation. Complaints can be made to the Complaints Officer/designee. (See below) Written complaints can also be made directly to the Office of Civil Rights. The Complaints Officer/designee will provide you with the appropriate address upon request.

Complaint Officer – phone # (518) 648-6141 Address: P.O. Box 250, White Birch Lane, Indian Lake, NY 12842

I have read the above notice and have been given the opportunity to ask questions and have those questions answered.

___________________________ _______________________

Signature of Patient/Client Date