Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

If you have any questions about this notice, please contact:


Amie Clancy
Director of Clinical Administration
445 Park Avenue
New York, NY 10022
(646) 625-4336
amie.clancy@childmind.org

OUR COMMITMENT TO YOUR PRIVACY

Child Mind Medical Practice, PLLC (the “Practice”) is dedicated to maintaining the privacy of your health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. These records are our property. However, we are required by law to:

  • maintain the confidentiality of your health information;
  • provide you with this notice of our legal duties and privacy practices concerning your health information;
  • follow the terms of our notice of privacy practices in effect at the time; and
  • notify you if a breach occurs that may have compromised the privacy or security of your health information.

This notice provides you with the following important information:

  • how we may use and disclose your health information; and
  • your rights regarding your health information.

WHO WILL FOLLOW THIS NOTICE

The privacy practices described in this notice will be followed by:

  • any health care professional who treats you at any of our locations;
  • all employees, medical staff, trainees, students or volunteers at any of our locations; and
  • all employees, trainees, students, volunteers or entities that are part of an organized health care arrangement with the Practice.

CHANGES TO THIS NOTICE

The terms of this notice apply to all records containing your health information that are created or retained by the Practice. We reserve the right to revise, change, or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any of your health information that we may receive, create, or maintain in the future. You may request a copy of our most current notice during any visit to our offices.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe the different ways in which the Practice may use and disclose your health information. Please note that every particular use or disclosure is not listed below. However, the different ways the Practice is permitted to use and disclose your health information do fall within one of the categories listed below. Please note that state law may further restrict how the Practice may use or disclose your health information in certain situations. In such situations, the Practice may be required to obtain a separate written authorization form from you prior to any disclosure of such information.

1.Treatment, Payment and Health Care Operations

Treatment. The Practice may use and disclose your health information to treat you. For example, Practice staff and physicians may consult with your child’s pediatrician to coordinate care or obtain medical history to help reach a diagnosis. The Practice may use or disclose your health information in order to treat you or to assist others in your treatment.

Payment. The Practice may use and disclose your health information in order to bill and collect payment for the services and items you may receive from the Practice. For example, the Practice may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and the Practice may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. The Practice also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, the Practice may use your health information to bill you directly for services and items.

Health Care Operations. The Practice may use and disclose your health information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that the Practice is well run. For example, the Practice may use and disclose your information for our operations, and the Practice may use your health information to evaluate the quality of care you receive from us or to conduct cost-management and business planning activities for the Practice. Further, the Practice may disclose your information to doctors, nurses, medical students, and other personnel for review and learning purposes.

Appointment Reminders. The Practice may use and disclose your health information to remind you that you have an appointment.

Treatment Alternatives/Health-Related Benefits and Services. The Practice may use and disclose your health information to inform you of treatment alternatives and/or health-related benefits and services that maybe of interest to you.

Marketing. The Practice may use your health information to make a marketing communication to you that (i) occurs in a face-to-face encounter with you; (ii) concerns products or services of nominal value; or (iii) concerns the Practice’s health-related products or services, provided that we are not receiving payment to make the communication. If you do not want to receive marketing communications (other than those that are in a newsletter or other general communication device), please contact Amie Clancy, Director of Clinical Administration.

In addition, if the Practice ever uses or discloses your health information to communicate with you based on your particular health status or condition, we will explain to you why you received the communication, and how the product or service relates to your health.

Fundraising. To support our business operations, the Practice may use information about you, including information about your age and gender, where you live or work, and the dates that you received treatment, in order to contact you to raise money to help the Practice operate. The Practice may share this information with Child Mind Institute, Inc. or another charitable organization that will contact you to raise money. We may contact you for fundraising efforts, but you may ask us not to contact you again.

  1. Other Routine Disclosures

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

De-Identified Information. We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number).

Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see or overhear discussion of your health information.

Research. Under certain circumstances, the Practice may use and disclose health information about you for research purposes to Child Mind Institute, Inc. and others. All research projects are subject to a special approval process and established protocols to ensure the privacy of protected health information. The Practice may disclose health information about you to people preparing to conduct a research project, and these researchers may contact you directly to see if you might be interested in participating. The health information they review does not leave our premises.

  1. Public Need

Required by Law. The Practice will use or disclose health information about you when required by applicable law.

Public Health Activities. The Practice may disclose your health information for public health activities, including generally to:

  • prevent or control disease, injury or disability;
  • maintain vital records, such as births and deaths;
  • report child abuse or neglect;
  • notify a person regarding potential exposure to a communicable disease;
  • notify a person regarding a potential risk of or spreading or contracting a disease or condition;
  • report reactions to drugs or problems with products or devices;
  • notify individuals if a product or device they may be using has been recalled;
  • notify appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; or
  • notify your employer under limited circumstances, related primarily to work place injury or illness or medical surveillance.

Abuse, Neglect, and Domestic Violence. The Practice may disclose your health information to a government authority if we believe you are a victim of abuse, neglect, or domestic violence. If the Practice makes such a disclosure, we will inform you of it, unless we think that informing you or your personal representative places you at risk of serious harm or is otherwise not in your best interest.

Health Oversight Activities. The Practice may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.

Lawsuits and Similar Proceedings. The Practice may use and disclose your health information in response to a court order if you are involved in a lawsuit or similar proceeding.

Law Enforcement. The Practice may disclose your 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 you have been the victim of a crime and we determine that: (i) we have been unable to obtain your agreement because of an emergency or your incapacity; (ii) law enforcement officials need this information immediately to carry out their law enforcement duties; and (iii) in our professional judgment, disclosure to these officers is in your best interests;
  • if we suspect that your death resulted from criminal conduct;
  • if necessary to report a crime that occurred on our property; or
  • if necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).

Serious Threats to Health or Safety. The Practice may use and disclose your health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or entity able to help prevent the threat.

Coroners, Medical Examiners, and Funeral Directors. The Practice may release health information to a coroner or medical examiner. The Practice may also release health information about patients to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation. The Practice may use or disclose your health information to organizations that handle organ and tissue procurement, banking, or transplantation.

Specialized Government Functions. The Practice may disclose your health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, the Practice may disclose your health information to federal officials for intelligence and national security activities authorized by law. Furthermore, the Practice may disclose your health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (i) for the institution to provide health care services to you, (ii) for the safety and security of the institution, and/or (iii) to protect your health and safety or the health and safety of other individuals.

Workers’ Compensation. The Practice may release your health information to workers’ compensation and similar programs.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

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

Requesting Restrictions. You have the right to request a restriction on our use or disclosure of your health information for treatment, payment or health care operations. Additionally, you have the right to request that the Practice limit its disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends.

Except under certain circumstances (for example, if you pay for the services provided in full and out of pocket), the Practice is not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your health information, you must make your request in writing to Amie Clancy, Director of Clinical Administration, at the contact information above. Your request must describe in a clear and concise fashion: (i) the information you wish to restrict; (ii) whether you are requesting to limit our use, disclosure or both; and (iii) to whom you want the limits to apply.

Confidential Communications. You have the right to request that the Practice communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that the Practice contact you by mail, rather than by telephone, or at home, rather than work. You do not need to give a reason for your request.

From time to time, our clinicians may offer patients the opportunity to communicate via e-mail, videoconferencing, or other electronic communication method, often at a patient’s request. While the Practice will always comply with applicable law and best practices (including those governing telemedicine), such methods of communication include certain unavoidable privacy risks, and the Practice will not be liable for improper disclosure of confidential information unless it is caused by our intentional misconduct. Of course, the Practice will not forward e-mails or other electronic communications to independent third parties without your prior written consent, except as authorized or required by law.

Although the Practice will endeavor to read and respond promptly to an e-mail or other electronic communication from a patient, the Practice cannot guarantee that any particular communication will be read and responded to within any particular period of time. Thus, please do not use e-mail or other electronic communications for medical emergencies or other time sensitive matters. If you believe an e-mail requires or invites a response and you have not received one within a reasonable time period, please follow up to determine whether the intended recipient received the e-mail and when he or she will respond.

In order to request a type of confidential communication, you must make a written request to Amie Clancy, Director of Clinical Administration, at the contact information above, specifying the requested method of contact, or the location where you wish to be contacted. The Practice will accommodate reasonable requests.

Inspection and Copies. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient health records and billing records, but not including psychotherapy notes. You must submit your request in writing to Amie Clancy, Director of Clinical Administration, at the contact information above, in order to inspect and/or obtain a copy of your health information. The Practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. The Practice may deny your request to inspect and/or copy in certain limited circumstances. In the event of a denial, the Practice will provide you with a summary of the information instead, and will also provide a written notice that explains the Practice’s reasons for providing only a summary. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the U.S. Department of Health and Human Services. If the Practice has 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.

You may request a review of our denial. Reviews will be conducted not by the person that denied your request, but by another licensed health care professional chosen by the Practice.

Amendment. You may ask the Practice to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for the Practice. To request an amendment, your request must be made in writing and submitted to Amie Clancy, Director of Clinical Administration, at the contact information above. You must provide the Practice with a reason that supports your request for amendment. The Practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, the Practice may deny your request if you ask us to amend information that is:

  • accurate and complete;
  • not part of the health information kept by or for the Practice;
  • not part of the health information which you would be permitted to inspect and copy; or
  • not created by the Practice, unless the individual or entity that created the information is not available to amend the information.

If the Practice denies 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 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 the Practice or with the Secretary of the U.S. Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

Accounting of Disclosures. You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures the Practice has made of your health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Amie Clancy, Director of Clinical Administration, at the contact information above. All requests for an accounting of disclosures must state a time period that may not be longer than six years. The first list you request within 12-month period is free of charge, but the Practice may charge you for additional requests within the same 12-month period. The Practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a Paper Copy of this Notice. If you received this notice in electronic form (e.g. e-mail), you are entitled to receive a paper copy of the Practice’s notice of privacy practices. You may ask the Practice to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Amie Clancy, Director of Clinical Administration, at the contact information above.

Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the U.S. Department of Health and Human Services Office for Civil Rights. To file a complaint with the Practice, contact Amie Clancy, Director of Clinical Administration, at the contact information above. All complaints must be submitted in writing. We cannot, and will not, retaliate against you for filing a complaint.

Right to Provide an Authorization for Other Uses and Disclosures. The Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to the Practice regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. Of course, the Practice is unable to take back any disclosures that we have already made with your permission. Please note that the Practice is required to retain records of your care.

Effective April 11, 2016