NOTICE OF PRIVACY PRACTICES

ORLEANS COMMUNITY HEALTH
200 OHIO STREET
MEDINA, NY 14103

NOTICE OF PRIVACY PRACTICES – Effective Date-March 1, 2016

This notice describes how medical information about you may be used and disclosed as well as how you can get access to the information.

PLEASE REVIEW IT CAREFULLY.

You should read this Notice before signing the Consent to the Use and Disclosure of Medical Information for Treatment, Payment and Health Care Operations.

WHO WILL FOLLOW THIS NOTICE:

All of the health care professionals, employees, students, volunteers, staff and other personnel of Orleans Community Health follow this Notice, and may share medical information with each other for treatment, payment or health care operations purposes as described in this Notice.

In this Notice, we use terms like “we,” “us” or “our” to refer to Orleans Community Health. All of the sites, locations, entities, and affiliates of Orleans Community Health follow the terms of this Notice and may share medical information with each other for treatment, payment or health care operations purposes as described in this Notice. Those sites, locations, entities, and affiliates are listed as follows:

Medina Memorial Hospital

200 Ohio Street
Medina, NY 14103

Orleans Community Health Center

Primary Care Center

Urgent Care

14789 Route 31
Albion, NY 14411

Outpatient Laboratory Services

Outpatient Physical Therapy Services

14789 Route 31
Albion, NY 14411

Lake Plains Dialysis Center

11020 W. Center Street
Medina, NY 14103

Lake Plains Dialysis Center

587 E. Main Street
Batavia, NY 14020

Long Term Home Health Care Program

11020 W. Center Street
Medina, NY 14103

Physical Therapy Rehabilitation Services

11020 W. Center Street
Medina, NY 14103

Community Partners Department

100 Ohio Street
Medina, NY 14103

Orleans Community Health Urology

Imbesat Daudi, MD
Urologist
711 Park Avenue
Medina, NY 14103

Medical Information

The terms “information” or “medical information” as used in this Notice include any information that we maintain that reasonably can be used to identify you, and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

Purpose of this Notice

This Notice describes how we may use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. ThisNotice also outlines our legal duties for protecting the privacy of your medical information, and explains your rights to have your medical information protected. We understand that your medical information is personal, and we are committed to protecting your privacy and ensuring that your medical information is not used inappropriately.

Our Responsibilities

We are required by law to maintain the privacy of your medical information, provide you with this Noticeof our legal duties and privacy practices with respect to your medical information, and to notify you if we have reason to believe that there has been a breach of your medical information due to unauthorized acquisition, access, use or disclosure. We will abide by the terms of this Notice.

How We May Use or Disclose Your Medical Information

The following categories describe examples of the way we use and disclose medical information:

For Treatment: We may use and disclose your medical information to other professionals who are treating you or providing you medical care and services. For example, your medical information may be disclosed to a physician treating you for a broken leg. We may disclose your medical information to physicians, nurses, technicians, hospitals or other healthcare providers to be sure those parties have all the information necessary to diagnose and treat you.

For Payment: We may use and disclose your medical information to others to bill and receive payment from you, a health care provider, a health plan, or a third party. For example, we may need to give information to your health plan about services you received so your health plan can remit payment to us. We may also tell your health plan about a treatment you are scheduled to receive in order to determine whether your plan will cover the treatment, or to receive prior approval to cover the treatment.

For Health Care Operations: We may use and disclose your medical information as necessary in order to effectively manage and maintain the quality of our business activities. For example, we may use your medical information to help us decide what, if any, additional services we should offer, to help us become more efficient, or for quality assessment activities on our behalf. We may disclose your medical information to any contractors, agents or other associates who need such information to assist us in carrying out our business activities. Our written contracts with such entities require that they protect and maintain the privacy of your medical information.

Appointment reminders: We may use and disclose medical information in order to contact you to remind you that you have an appointment for treatment or services.

Treatment Alternatives and Health-Related Benefits and Services: We may use your medical information to inform you of services or programs that we believe would be beneficial to you. We may call, mail or e-mail you information about these services or goods. For example, we may contact you to make you aware of new products, supply you product information, or advise you of new treatments or programs that may be available to you.

Individuals Involved in Your Care or Payment for Your Care: In case you become incapacitated, or in an emergency, or when you agree or fail to object when given the opportunity to do so, we may release your medical information to a family member or friend who is involved in your medical care or who helps pay for your care. If you would like us to refrain from releasing your medical information to a family member or friend, please notify us in writing addressed to the Privacy Officer at Orleans Community Health.

Fundraising Activities:  We may use demographic information about you to contact you in an effort to raise money for one or more of our facilities and operations through our foundations. Any fundraising communications you receive will contain information on how to elect not to receive further fundraising contacts. If you do not wish to be contacted for fundraising activities, please notify us in writing addressed to the Privacy Officer at Orleans Community Health.

Patient Information Directory:  If you are a patient at our hospital, your name, location, general condition (e.g., “satisfactory”), and your religious affiliation will be included in our patient directory. This Directory information about you, except for your religious affiliation, may be released to people who ask for you by name. Information contained in the Directory may also be provided to a member of the clergy, such as a priest or a rabbi, even if they do not ask for you by name. This information is provided so that your family, friends and clergy may visit you and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release medical information about you to a friend or family member who is involved in your care or payment for your care. We may also disclose medical information about you to an entity assisting in disaster relief (e.g., The Red Cross) so that your family can be notified about your condition, status and location.

Special Situations

We are also allowed by law to use and disclose your medical information without your authorization for the following special situations:

As Required by Law: We may use and disclose your medical information when required to do so by federal, state or local law.

Judicial and Administrative Proceedings: If you are involved in a legal proceeding, we may disclose your medical information in response to a court or administrative order. We may also release your medical information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request, or to obtain an order protecting the information requested.

Health Oversight Activities: We may use and disclose your medical information to health oversight agencies for activities authorized by law. These oversight activities are necessary for the government to monitor the health care system, government benefit programs, compliance with government regulatory programs, and compliance with civil rights laws.

Law Enforcement: We may disclose your medical information, within limitations, to law enforcement officials for several different purposes, which include, but are not limited to, the following:

  • To comply with a court order, warrant, subpoena, summons, or other similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • To report a death we suspect may have resulted from criminal conduct;
  • To report criminal conduct we believe in good faith to have occurred on our premises; and
  • To report a crime, the location of a crime, and the identity, description and location of the individual who committed the crime, in an emergency situation.

Inmates: If you are an inmate of a correctional facility, we may disclose medical information about you to the facility or any officers, staff or agents of the facility if the disclosure of your medical information is necessary for your own health and safety, for the health and safety of other individuals, or for the safety and security of officers, staff and agents of the facility.

Public Health Activities: We may use and disclose your medical information for public health activities, including the following:

  • To prevent or control disease, injury, or disability;
  • To report child abuse or neglect;
  • To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition.

Serious Threat to Health or Safety: If there is a serious threat to your health and safety or the health and safety of the public or another person, we may use and disclose your medical information to someone able to help prevent the threat.

Organ/Tissue Donation: If you are an organ donor, we may use and disclose your medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank.

Coroners, Medical Examiners, and Funeral Directors: We may use and disclose medical information to a coroner or medical examiner. This disclosure may be necessary to identify a deceased person or determine the cause of death. We may also disclose medical information, as necessary, to funeral directors to assist them in performing their duties.

Workers’ Compensation: We may disclose your medical information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.

Military and Veterans Activities: If you have been or are a member of the Armed Forces, we may use and disclose your medical information to military command authorities, the Department of Defense, or the Department of Veterans Affairs. Medical information about foreign military personnel may be disclosed to foreign military authorities.

National Security and Intelligence Activities: We may disclose your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose your medical information to authorized federal officials so they may provide protective services for the President and others, including foreign heads of state.

Research: We may use and disclose your medical information for certain limited research purposes. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project, assesses a number of specific issues, and determines that appropriate privacy safeguards are in place to allow the use of medical information in the research project.  In most cases we will ask for your written permission to disclose your medical information for these research activities if the researcher will have access to any information that identifies you, such as your name or address. However, under some circumstances we may use and disclose your medical information without your written consent if doing so poses minimal risk to your privacy. For instance, we may release your medical information to people preparing to conduct a research project, so long as the information identifying you does not leave Orleans Community Health.

Rules Governing the Disclosure of Mental Health, Chemical Dependency and HIV-Related Information:

Uses and disclosures of mental health treatment, drug and/or alcohol abuse records, and HIV-Related information that may be made without a valid authorization from you are legally limited, and in some cases prohibited all-together, by applicable New York State laws and regulations. In such instances we will comply with the provisions of the more stringent legal protections under New York law regarding disclosure of such information.

Other Uses and Disclosures of Your Medical Information: Except for the uses and disclosures described and as set forth above in this Notice, other uses and disclosures of your medical information will be made only with your written authorization, including the disclosure of any psychotherapy notes, or disclosures for marketing purposes. If you authorize us to use or disclose your medical information, you may revoke that authorization, in writing, at any time by submitting your revocation to the Privacy Officer at Orleans Community Health. However, we will be unable to take back any uses or disclosures already made with your permission. If you revoke your authorization, we will no longer use or disclose your medical information as specified by the revoked authorization, except to the extent that we have taken action in reliance on your authorization.

Your Rights Regarding Your Medical Information

You have the following rights regarding medical information we maintain about you:

Right to Request Restrictions: You have the right to request restrictions on how we use and disclose your medical information for treatment, payment or health care operations. 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.  Also by law you have the right to request a restriction of the disclosure of your medical information to a health plan if the disclosure pertains to services for which you have paid us out-of-pocket in full. To request restrictions, you must make your request in writingand submit it to the Privacy Officer at Orleans Community Health.

Right to Request Confidential Communications: You have the right to request that we communicate with you in a certain manner or at a certain location regarding the services you receive from us. For example, you may ask that we only contact you at work or only by mail. To request confidential communications, you must make your request in writing and submit it to the Privacy Officer at Orleans Community Health. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will attempt to accommodate all reasonable requests.

Right to Inspect and Receive Copies: You have the right to inspect and receive a copy of any medical information that we maintain about you. If the requested medical information is maintained electronically by us, we will provide you with a copy in an electronic format.  If you wish to inspect and receive a paper copy of your medical information, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer of Orleans Community Health. If you request a paper copy of your medical information, we may charge you a fee for the costs of copying, mailing or preparing the requested documents. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you believe that your medical information is incorrect or incomplete, you may request that we amend your information for as long as we maintain the information. To request an amendment, you must make your request in writing and provide the reason(s) for the requested amendment by filling out the appropriate form provided by us and submitting it to the Privacy Officer at Orleans Community Health. We may deny your request for an amendment if it is not in writing and/or does not include a reason to support your request.  In addition, we may deny your request to amend if the information:

  1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  2. Is not part of the medical information maintained by or for us;
  3. Is not information that you would be permitted to inspect or copy;
  4. Is accurate and complete.

If we deny your request to amend, you will be notified of the reason for the denial and given the opportunity to file a written statement of disagreement with us.

Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures we make of your medical information. Please note that certain disclosures, such as those made for treatment, payment or health care operations, as well as disclosures that you have requested or authorized, need not be included in the accounting we provide to you. Also, we need not include disclosures that have been made for national security or intelligence purposes, and disclosures to correctional institutions or law enforcement officials. To request an accounting of disclosures, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at Orleans Community Health. Your request must state a time period which may not be longer than six years prior to the date of your request, and which may not include dates prior to March 1, 2016. The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice at any time, even if you have previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact the Privacy Officer in writing at Orleans Community Health.

Right to File a Complaint: If you would like more information about our privacy practices, or have any questions about this Notice, or would like to file a complaint about our privacy practices, please direct your inquiries in writing to: the Privacy Officer at Orleans Community Health. You may also file a complaint with the Secretary of the Department of Health and Human Services. We will supply you with the address to file such a complaint upon request. You will not be retaliated against or penalized for filing a complaint.

Changes to this Notice

We reserve the right to change the terms of this Notice at any time. We reserve the right to make the new Notice provisions effective for all medical information we currently maintain, as well as any medical information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise the Notice on our website. Each version of the Notice will have an effective date listed on the first page.

Please direct any of your questions or concerns to:

Nicole Miller, Privacy Officer
Orleans Community Health 
Phone Number (585) 798-8140
E-mail: nmiller@medinamemorial.org
Address: 200 Ohio Street, Medina, NY 14103