and affiliate of NYU Langone Medical Center
  Referring Physicians  
  For Internal Use Only  
Notice of Privacy Practices
The Health Insurance Portability and Accountability Act (“HIPAA”)
This notice describes how medical information about you may be used, disclosed and how you can get access to this information. Please review it carefully.
How we may use and disclose your protected health information (“PHI”) without your permission.
Treatment, Payment, or Health Care Operations. Below are examples of how Federal law permits use or disclosure of your PHI for these purposes without your permission.
Treatment: Exam:
PHI obtained will be used to perform requested exam. We will document information related to the exam performed and services provided in your record.
Payment:
We may contact your insurer, payor, or other agent and share your PHI with that entity to determine whether it will pay for your examination and the payment amount. We may also contact you about a payment or balance due for services performed.
Health Care Operations:
Service. Your PHI may be used to monitor the effectiveness of our services.Other Special Circumstances:We are permitted, under federal and applicable state law, to use or disclose your PHI without your permission only when certain circumstances may arise, as described below.
Business Associates:
We provide some services through other companies termed: “business associates”. Federal law requires us to enter into business associate contracts to safeguard your PHI Individuals involved in your care or payment for care: We may disclose your PHI to a personal representative, or family member involved in your medical care. Disclosures to parents or legal guardians: If you are a minor, we may release your PHI to your parents or legal guardian when we are permitted or required under the law.
Disclosures to Parents or Legal Guardians:
If you are a minor, we may release your PHI to your parents or legal guardian when we are permitted or required under the law.
Worker’s Compensation:
We may disclose your PHI to the extent authorized and necessary to comply with laws relating to worker’s compensation or similar programs established by law.
Law Enforcement:
We may disclose your PHI for law enforcement purposes as required by law or in response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a death resulting from criminal conduct; about crimes on the premises or against a member of our workforce; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime.
As Required by Law:
We must disclose your PHI when required to do so by applicable federal or state law.
Judicial and Administrative Proceedings:
If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request or other lawful process. Request communication of PHI by alternative means or locations. Ex: Calls via cell phone only.
Public Health:
We may disclose your PHI to federal, state, or local authorities, or other entities charged with preventing or controlling disease, injury, or disability for public health activities.
Health Oversight Activities:
We may disclose your PHI to an oversight agency for activities authorized by law, including audits, investigations, and inspections, as necessary for our licensure and for government monitoring for the health care system, government programs, and compliance with federal and applicable state law.
United States Department of Health and Human Services (“HHS”):
Under federal law, we are required to disclose your PHI to HHS to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.
Although we may not routinely engage in the following, under federal and applicable state law, we are allowed to use or disclose your PHI without your permission to assist with the below activities or parties:
Research, Coroners, Medical Examiners, Funeral Directors, Administrator or Executor, Organ or Tissue Procurement Organizations, Correctional institution, To avert a serious threat to health or safety, Protective Services for the President and others, National Security and Intelligence activities, Military and Veterans, and Notifications in disaster relief.
Note:
This office does contact individuals to provide appointment reminders or information about treatment alternatives or other health–related benefits and services that may be of interest to the individual.
Complaints:
If you believe your privacy rights have been violated, you can file a complaint with the privacy officer at the address above or the Secretary of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint.
Changes to this Notice:
If you believe your privacy rights have been violated, you can file a complaint with the privacy officer at the address above or the Secretary of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint.
Effective Date:
This notice is effective as of 04/14/2003.
We are required by federal and applicable state law to protect the privacy of your health information and to provide you with this Notice.
Our staff is required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to PHI that is oral, written or electronic.
We will obtain your written authorization before using or disclosing your PHI for purposes other than those described above. You may revoke this authorization at any time by submitting a written notice.
You have the following rights with respect to your PHI.
All requests must be in writing.
Obtain a paper copy of the Notice upon request:
Contact privacy officer at the above address / phone number. This right extends to those that have agreed to receive the Notice electronically.
Inspect and obtain a copy of your PHI:
You have the right to access and copy your PHI contained in the “designated record set” which includes examination and billing records. Fees may be charged for expenses of fulfilling your request.
Request an amendment of PHI:
If you feel that your PHI is incomplete or incorrect, you may request an amendment.
Receive an accounting of disclosures of PHI:
After April 14, 2003, you have the right to request an accounting of your PHI disclosures for purposes other than treatment, payment, or health care operations.
Request communication of PHI by alternative means or locations:
Ex: Calls via cell phone only.
Request restriction on certain uses and disclosures of PHI:
We are not required to agree to request.
The following entities will share Protected Health Information with each other, as necessary, to carry out treatment, payment or healthcare operations relating to the organized healthcare arrangement:
Gramercy MRI & Diagnostic Radiology 380 Second Ave, New York, NY 10010
212-477-8180
Metropolitan Diagnostic Imaging 224 Seventh Street, Garden City, NY 11530
516–747-0161
Queens Medical Imaging, P.C. 69-15 Austin Street, Forest Hills, NY 11375
718-544-5100
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