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Privacy Policy

This notice describes how medical 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:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

Who will follow this notice
This notice describes the information privacy practices followed by our employees, staff and other office personnel. The practices described in this notice will also be followed by care providers you consult with by telephone (when your regular care providers from our agency are not available) who provide “coverage” for your regular care providers.

Your health information
This notice applies to the information and records we have about your or your child’s health, health status, personal or family history and the services you receive at Andrus.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose information about you and describes your rights and our obligations regarding the use and disclosure of that information.

How we may use and disclose health information about you:

For Treatment
We may use information about you or your child to provide treatment or services. We may disclose information to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you or your child and your health.

For example, your doctor may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.

Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.

For Payment
We may use and disclose information about you or your child so that the treatment and services you receive at Andrus may be billed to and payment may be collected from you, an insurance company or a third party (e.g. State Education Department). For example, we may need to give your health plan information about a service received here so your health plan will pay us or reimburse you for the service. 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 health information about you or your child in order to run the office and make sure that you and our other patients receive quality care. For example, we may use treatment information to evaluate the performance of our staff in caring for you. We may also use information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.

Health Oversight Activities
We may disclose treatment information to a health oversight agency for audits, investigations, inspections, risk management or licensing requirement purposes. These disclosures may be necessary for certain state and federal agencies to monitor government programs and compliance with civil rights laws.

Appointment Reminders
We may contact you as a reminder that you have an appointment for treatment or medical care at Andrus.

Treatment Alternatives
We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services
We may tell you about health-related products or services that may be of interest or benefit to you or your child.

Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing (at the address listed at the top of this Notice) that you do not wish to receive such communications.

You may revoke your Consent to release information for any of the above stated reasons at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures which occurred before that time.

If you do revoke your Consent, we will not be permitted to use or disclose information for purposes of treatment, payment or health care operations, and we may therefore choose to discontinue providing you with treatment and services.

Special situations
We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety
We may use and disclose treatment information about you or your child when necessary to prevent a serious threat to health and safety of you, your child, the public or another person.

Required By Law
We will disclose treatment information about you when required to do so by federal, state or local law.

Research
We may use and disclose treatment information about you or your child for research projects that are subject to a special approval process. We will ask you for your 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 at Andrus.

Military, Veterans, National Security and Intelligence
If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release treatment information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation
We may release treatment information about you or your child for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks
We may disclose treatment information about you or your child for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities
We may disclose treatment information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor government programs and compliance with civil rights laws.

Lawsuits and Disputes
If you or your child are involved in a lawsuit or a dispute, we may disclose treatment information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose treatment information about you in response to a subpoena.

Law Enforcement
We may release treatment information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors
We may release treatment information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable
We may use or disclose treatment information about you or your child in a way that does not personally identify you or reveal who you are.

Family and Friends
We may disclose treatment information about you or your child to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose treatment information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal treatment information to your spouse when you bring your spouse with you into a treatment session where treatment is discussed.

Minimum Necessary
In all cases when we disclose information about you or your child we will only provide the minimum necessary information to meet the requirement in order to ensure the highest level of privacy.

Other uses and disclosures of health information
We will not use or disclose treatment information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you or your child, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you or your child for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you or your child, we cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.

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

Right to Inspect and Copy
You have the right to inspect and copy treatment information regarding you or your child, such as medical and billing records, that we use to make decisions about care.

You must submit a written request to:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

…in order to inspect and/or copy treatment information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend
If you believe health information we have about you or your child is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by Andrus.
To request an amendment, complete and submit a Medical Record Amendment/Correction Form to:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

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: a) We did not create, unless the person or entity that created the information is no longer available to make the amendment. b) Is not part of the treatment information that we keep. c) You would not be permitted to inspect and copy. d) Is accurate and complete.

Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you or your child for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in
writing to:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

It 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, electronically). 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 health information we use or disclose about you or your child for treatment, payment or health care operations. You also have the right to request a limit on the treatment information we disclose about you or your child to someone who is involved in your care or the payment for it, like a family member or friend.

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 may complete and submit a Request For Restricting Uses and Disclosures and Confidential Communications Form Information to:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

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 may complete and submit the Requests For Restricting Uses and Disclosures and Confidential Communications to:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

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 it electronically, you are still entitled to a paper copy. To obtain such a copy, contact:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

Changes to this notice
We reserve the right to change this notice, and to make the revised or changed notice effective for treatment information we already have about you or your child as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contac:

Koji Mabuchi
Director of Quality Assurance and Compliance
1156 North Broadway
Yonkers, New York 10701
P: 914.965.3700 ext 1207
kmabuchi@jdam.org

You will not be penalized for filing a complaint.