NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION, PROTECTED HEALTH INFORMATION (PHI)* ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY PRIVACY
Citywide Urgent Care (Citywide) is required by state and federal law to maintain the privacy of your protected health information (PHI). PHI includes any identifiable information about your physical or mental health, the health care you receive, and the payment for your health care.
Citywide is required by law to provide you with this notice to tell you how it may use and disclose your PHI and to inform you of your privacy rights. Citywide must follow the privacy practices as set forth in its most current Notice of Privacy Practices.
This notice refers only to the use/disclosure of PHI. It does not change existing law, regulations and policies regarding informed consent for treatment.
CHANGES TO THIS NOTICE
Citywide may change its privacy practices and the terms of this notice at any time. Changes will apply to PHI that Citywide already has as well as PHI that Citywide receives in the future. The most current privacy notice will be posted in Citywide’s facilities and will be available on request. Every privacy notice will be dated.
HOW DOES CITYWIDE USE AND DISCLOSE PHI?
Citywide may use/disclose your PHI for treatment, payment and health care operations without your authorization. Otherwise, your written authorization is needed unless an exception listed in this notice applies.
USES/DISCLOSURES RELATING TO TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS
The following examples describe some, but not all, of the uses/disclosures that are made for treatment, payment and health care operations.
FOR TREATMENT - Consistent with its regulations and policies, Citywide may use/disclose PHI to doctors, nurses, service providers and other personnel (e.g., interpreters), who are involved in delivering your health care and related services. Your PHI will be used to help make a determination on your application for Citywide services, to assist in developing your treatment and/or service plan and to conduct periodic reviews and assessments. PHI may be shared with other health care professionals and providers to obtain prescriptions, lab work, consultations and other items needed for your care. PHI will be shared with Citywide service providers for the purposes of referring you for Citywide services and then for coordinating and providing the Citywide services you receive.
TO OBTAIN PAYMENT - Consistent with the restrictions set forth in its regulations and policies, Citywide may use/disclose your PHI to bill and collect payment for your health care services. Citywide may release portions of your PHI to the Medicaid or Medicare program or a third party payer to determine if they will make payment, to get prior approval and to support any claim or bill. FOR HEALTH CARE OPERATIONS - Citywide may use/disclose PHI to support activities such as program planning, management and administrative activities, quality assurance, receiving and responding to complaints, compliance programs, audits, training and credentialing of health care professionals, and certification and accreditation.
USES/DISCLOSURES REQUIRING AUTHORIZATION
Citywide is required to have a written authorization from you or your personal representative with the legal authority to make health care decisions on your behalf for uses/disclosures beyond treatment, payment and health care operations unless an exception listed below applies. You may cancel an authorization at any time, if you do so in writing. A cancellation will stop future uses/disclosures except to the extent Citywide has already acted based upon your authorization.
- For guardianship or commitment proceedings when Citywide is a party
- For judicial proceedings if certain criteria are met
- For protection of victims of abuse or neglect
- For research purposes, following strict internal review
- If you agree, verbally or otherwise, Citywide may disclose a limited amount of PHI for the following purposes:
- Clergy – Your religious affiliation may be shared with clergy
- To Family and Friends – Citywide may share information directly related to their involvement in your care, or payment for your care
- To correctional institutions, if you are an inmate
- For federal and state oversight activities such as fraud investigations, usual incident reporting, and protection and advocacy activities
- If required by law, or for law enforcement or national security
- To avoid a serious and imminent threat to public health or safety
- For public health activities such as tracking diseases and reporting vital statistics
- Upon death, to funeral directors and certain organ procurement organizations
YOUR RIGHTS You, or a personal representative with legal authority to make health care decisions on your behalf, have the right to:
- Request that Citywide use a specific address or telephone number to contact you. Citywide is not required to comply with your request.
- Obtain, upon request, a paper copy of this notice or any revision of this notice, even if you agreed to receive it electronically.
- *Inspect and copy PHI that may be used to make decisions about your care. Access to your records may be restricted in limited circumstances. If you are denied access, in certain circumstances, you may request that the denial be reviewed. Fees may be charged for copying and mailing.
- *Request additions or corrections to your PHI. Citywide is not required to comply with a request. If it does not comply with your request, you have certain rights.
- *Receive a list of individuals who received your PHI from Citywide (excluding disclosures that you authorized or approved, disclosures made for treatment, payment and healthcare operations and some required disclosures).
- *Ask that Citywide restrict how it uses or discloses your PHI. Citywide is not required to agree to a restriction. * These requests must be made in writin
If you want to obtain further information about Citywide’s privacy practices, or if you want to exercise your rights, or you feel your privacy rights have been violated, or you want to file a complaint, you may contact: Citywide Privacy Officer, Citywide Urgent Care, 2361 Nostrand Avenue, Brooklyn, NY 11210,
Phone: 718-866-4526, ext: 104, Fax: 718-703-7789, E-mail: email@example.com A complaint must be made in writing.
You also may contact Citywide Urgent Care for more information or assistance.
No one may retaliate against you for filing a complaint or for exercising your rights as described in this notice.
You also may file a complaint with the Secretary of Health and Human Services, Office for Civil Rights, U.S. Department of Health and Human Services, JFK Federal Building, Room 1875, Boston, MA. 02203.