NOTICE OF PRIVACY PRACTICES
Edward Gelber, M.D.
26 Court Street #709
Brooklyn, NY 11242
Tel: (917) 818-3011
Fax: (917) 768-2011
THIS NOTICE DESCRIBES HOW PHI ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE REGARDING PHI
It is our legal duty and policy to maintain the confidentiality of protected health information(hereafter “PHI”) about all our patients (hereinafter “individual”) by only using and disclosing it as permitted by applicable HIPAA and state law requirements.
We are also required to provide a Notice of Privacy Practices (hereinafter “Privacy Notice”). This Privacy Notice describes the ways in which we may use and disclose your PHI and your rights and certain obligations we have regarding the use and disclosure of your PHI.
As required by law, we will only use or disclose your PHI in ways consistent with what is stated in our Privacy Notice.
The effective date of this Privacy Notice is November 24, 2012.
We reserve the right to change the terms of this Privacy Notice and to make a new Privacy Notice effective for all PHI we maintain. In the event of a change to our Privacy Notice, we will provide you with the new Privacy Notice by mail or email if you have indicated that you desire to receive notifications electronically.
We have designated a Privacy Officer, Dr. Edward Gelber, whom you may consult to ask questions and bring up concerns you might have about your PHI and how it is handled. You can reach our Privacy Officer by calling (917) 818-3011 or by fax at (917) 768-2011 or by mail at 26 Court Street #709 Brooklyn, NY 11242, Attn: Privacy Officer.
ACKNOWLEDGMENT OF RECEIPT OF THIS PRIVACY NOTICE
You are receiving our current Privacy Notice and are asked to sign an acknowledgment that you have received it. You may provide the signed acknowledgment by: signing the last page of this Privacy Notice and returning it to the reception desk or a staff member, or by mailing or emailing or faxing it to Dr. Gelber’s office, Attn: Privacy Officer.
If your initial contact with our office is through electronic mail, you will be asked to acknowledge receipt of this Privacy Notice by replying to our electronic message that contains the Privacy Notice.
HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU
The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use and disclose your PHI as reasonably necessary to provide for your treatment. We do not need to obtain your permission, written or otherwise, for us to do this. We may disclose PHI about you to doctors, nurses, technicians or other healthcare personnel who are involved in taking care of you.
For Payment. We may use and disclose PHI about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a procedure performed in our office so your health plan will pay us or reimburse you for the procedure. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose PHI about you for healthcare operations. These uses and disclosures are necessary to run our office and make sure that all individuals receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you.
Appointment Reminders, Test Results. We may use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at our office. In addition, we may use and disclose PHI to notify you of test results.
Treatment Alternatives. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose PHI to tell you about health related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. We may release PHI about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in a hospital.
Research. Under certain circumstances, we may use and disclose PHI about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with individuals’ need for privacy of their PHI. Before we use or disclose PHI for research, the project will have been approved through this research approval process, but we may, however, disclose PHI about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the PHI they review does not leave our office. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.
As Required By Law. We will disclose PHI about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. We may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose PHI about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.
Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you 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.
Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
- 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 the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at our office; and
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI about an individual to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may release PHI about you 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 PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Pursuant to an Authorization. We will require a signed authorization form before we disclose your PHI to a third party for reasons other than those listed above. We will retain a copy of any signed authorization you give us that is attached to a request to us for your PHI. We will also keep a record of when, to whom and what we provided in response to the request for disclosure. If you have signed an authorization for use to use or disclose your PHI, and decide you want to revoke the authorization, you have the right to revoke it. You must revoke the specific authorization in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer, before your revocation is effective. Once we receive the revocation, or have actual knowledge that you have revoked the authorization, we will make a note of it to assure that we do not make future disclosures pursuant to your original authorization.
YOUR RIGHTS REGARDING PHI ABOUT YOU You have the following rights regarding PHI we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by us will review your request and the denial. 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 feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by Edward Gelber, MD.
To request an amendment, your request must be made in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the PHI kept by or for us;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your PHI that we have made. (We do not have to provide an accounting of disclosures made for treatment, payment or healthcare operations, or pursuant to a signed authorization or where you did not orally deny authorization, or of certain disclosures required by law.)
To request this list or accounting of disclosures, you must submit your request in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure you had. 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.
To request restrictions, you must make your request in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right 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. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing and mail or email or fax it to Dr. Gelber’s office, Attn: Privacy Officer. 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.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice electronically by sending a written request and providing a valid email address to which you would like an electronic copy of this notice sent. To obtain a paper copy of this notice, please call, fax or mail your request to this office and provide a mailing address where you would like it sent.
Our current Privacy Notice will also be posted in our office for you to review.
If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint with the us, contact the Privacy Officer at (917) 818-3011. All complaints must be submitted in writing by mail or email or fax to Dr. Gelber’s office, Attn: Privacy Officer. You also have the right to complain to the Secretary of the Department of Health and Human Services by contacting him/her at: 200 Independence Avenue, S.W., Washington, DC 20201. You will not be penalized for filing a complaint.