NOTICE OF PRIVACY PRACTICES DBA IDCC Health Services

Effective Date: 11/4/2014

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.

The United States Department of Health and Human Services has issued medical privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). We are required by law to maintain the privacy of your protected health information and provide you with this notice of our legal duties and privacy practices concerning protected health information. We must follow the terms of this notice.

This notice is designed to inform you about DBA IDCC Health Services (or “IDCC Health”) privacy practices. Our employees, staff, students, and all office personnel follow these privacy practices. This notice will describe how we may use and disclose information that is called “protected health information” (“PHI”). We will also outline your rights and our obligations regarding our use and disclosure of that information.

Any changes to this notice will be posted at IDCC Health.

If you have any questions or issues regarding this notice please contact IDCC Health’s privacy officer:

Stephen Gersten
(718) 375-1200, x414

Uses and Disclosures of your Identifiable Health Information Without your Permission

We may use and disclose your personal healthcare information without your permission in the following situations.

Treatment, Payment, and Healthcare Operations

We will use and disclose your identifiable health information for treatment, payment and healthcare operations purposes. We do not need your permission to use or disclose your identifiable health information for these purposes.

Treatment includes:

• Direct provision of mental health services
• Consultation (for example, a therapist, supervisor, and/or a psychiatrist working for IDCC Health may consult with each other regarding your treatment)
• Transfer between therapists

Payment includes:

• Obtaining eligibility verification, pre-authorization, ongoing authorization from
  other providers, agencies, insurance companies
• Billing to other providers, agencies, insurance companies
• Collection
• Communicating with third party payors concerning claims (for example, we may contact your health insurer to certify that you are eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your treatment)

Health Care Operations include:

• Matters related to quality improvement (for example, your therapist’s supervisor or quality assurance staff may review your record to ensure provision of high quality care)
• Utilization Review
• General Administration
• Business planning and management
• Legal and auditing services
• Site visits pertaining to licensing and accreditation

Business Associates

We may share your PHI with third parties that perform various business activities for IDCC Health.

Other Disclosures

We may disclose PHI to a health oversight agency for activities authorized by law. These include government agencies that oversee the mental health care system, government benefit programs such as Medicaid, and other government programs regulating mental health care.

New York State law also limits how we may disclose information from your clinical record. We may not release information from your clinical record except in certain circumstances. We may share your information with other facilities that provide services to you that are licensed or operated by the Department of Mental Hygiene or approved as part of a local services plan and the Department of Mental Hygiene. The information that we do release will be limited to what is needed in light of the reason for the disclosure. The people or entities that receive your information must keep that information confidential.

We may release information from your clinical record to these people or entities without your
permission:

• You or certain people who have the right to information about you.
• A court that orders us to disclose your records.
• The Mental Hygiene Legal Service.
• Attorneys who represent you in court when your involuntary hospitalization or assisted outpatient treatment is an issue.
• The Justice Center for the Protection of People with Special Needs, which is a successor entity to the now-defunct Commission on Quality of Care for the Mentally Disabled.
• The State Commission of Correction’s Medical Review Board if it asks for your records in connection with the death of a named person.
• If your treating psychiatrist or psychologist determines that you present a serious and imminent danger to someone, we may provide your records to the person in danger and a law enforcement agency.
• To the State Board for Professional Medical Conduct or the Office of Professional Discipline, unless you are the subject of one of those entities’ investigations.
• To a correctional facility when its chief administrative officer asks for information about a named inmate of the facility.
• To the department of corrections and community supervision when it asks for information about a person who has been or will be released within in four weeks.
• To a director of community services when a mental health professional who is currently providing your treatment determines, in the exercise of reasonable professional judgment, that you are likely to engage in conduct that would result in serious harm to you or to others.
• To the State Division of Criminal Justice Services in order to provide certain information to the Commissioner of Mental Health.
• To the State Division of Criminal Justice Services in order to provide certain information to the Federal Bureau of Investigation related to a federal background check of a person who purchases a firearm.
• Directly to the Federal Bureau of Investigation related to a federal background check of a person who purchases a firearm.
• To the State Division of Criminal Justice Services in connection with New York State firearm license laws, but only your name and non-clinical identifying information.

Only if the New York Commissioner of the Office of Mental Health agrees, we may disclose your information without your permission in some cases, including:

• • Disclosures of your records to government agencies, insurance companies, and other third parties who are responsible for making payments to you or to others on your behalf. These entities must keep your information confidential.
  • Disclosures of your identifying data concerning any hospitalization to people and agencies who are trying to find missing persons or in connection with criminal investigations.
  • Disclosures of information that does not identify you to qualified researchers if our facility’s institutional review board approves.
  • If we ask the coroner, county medical examiner, or chief medical examiner in New York City to investigate your death, discloses of your records to the investigating
    entity.
  • Disclosures of your information when it is necessary to prevent imminent serious harm to you or another person.
  • Disclosures of your information to a district attorney when this is necessary for a criminal investigation of patient or client abuse.
  • Disclosures of information made to appropriate people and entities when necessary to protect the public from a sex offender who needs civil management.
  • Disclosures of information made to the attorney general, a case review panel, or psychiatric examiners when they are authorized, under law, to have that information.

New York State also protects confidential HIV-related information. We may not disclose that information to anyone except in special circumstances. We may disclose your confidential HIV related information without your permission in these circumstances:

• We may disclose to an authorized health care provider to whom the information would be relevant for the health of the provider.
• If disclosure is needed to provide appropriate care to you, your child, or one of your contacts, we may disclose to an authorized health care provider.
• We may disclose to authorized health service staff who work with your medical records.
• We may disclose to a foster care or adoption agency if the disclosure is relevant to the adoption of a child.
• We may disclose when a court orders us to do so.

Uses and Disclosure of Your Mental Health Information with Your Permission

Interborough may ask you for permission to use or disclose information in some
circumstances. We must have your authorization to use or disclose the following
information.

• Any protected health information that we use or disclose for marketing purposes.
• Any protected health information that we sell and for which we would receive payment.
• Psychotherapy notes, unless:

We will only make other uses and disclosures of your identifiable health information that are not
described in this notice with your written authorization.

You may revoke your authorization for our use of your identifiable health information. You must revoke your authorization in writing.

New York State law also limits how we may disclose information from your clinical record with your permission. We need your permission or someone else’s permission to release your clinical records in some cases:

• If you consent, we may provide your records to the Medical Review Board of the State Commission on Correction in matters that concern you.
• If you or someone who you authorize to give consent on your behalf agrees, we may provide your records to people and entities who need your records as long as this disclosure will not harm you.

New York also protects your confidential HIV-related information. Except for the disclosures described above, we may not disclose your confidential HIV-related information without your permission. If we have your permission, we may disclose that information to you or anyone you authorize, through a release, to receive that information.

Your Rights regarding Your Protected Health Information

Right to Inspect and Copy

You have the right to inspect or copy mental health information used to make decisions about your care. You must submit your request in writing to the Privacy Officer at Interborough Developmental & Consultation Center, 201 Kings Hwy Brooklyn, NY 11223. We may charge a reasonable cost-based fee for copies that includes only the cost of labor for copying the information, supplies for copying the information, and postage if necessary.

You may not inspect or copy the following protected health information:

• Psychotherapy notes.
• Information we put together for a legal proceeding.
• Information that we cannot disclose under the federal Clinical Laboratory Improvements Amendments of 1988.
• Information that is exempt from the federal Clinical Laboratory Improvements Amendments of 1988.

We may decide that you cannot access certain other records in some circumstances. We may deny your request to inspect or copy your mental health information when:

• a licensed health care professional, in the exercise of professional judgment, determines that access is reasonably likely to endanger your life or physical safety or someone else’s life or physical safety
• the records requested reference another person and a licensed health care professional, in the exercise of professional judgment, determines that access is reasonably likely to endanger that person’s life or physical safety
• your personal representative has requested access and a licensed health care professional, in the exercise of professional judgment, determines that access is reasonably likely to endanger your life or physical safety or someone else’s life or physical safety

If you are denied access for these reasons, you may request that the denial be reviewed.

Right to Make Changes

If you believe that Interborough Developmental & Consultation Center, Inc. has protected health information about you that is inaccurate or incomplete, you may ask us to make changes to correct the information. We ask that you contact the Privacy Officer in writing and provide as much detail as possible as to what information needs to be changed and why. We may deny your request if you ask us to amend information that IDCC Health did not create, we deny you access to that information, or if IDCC Health believes the information is complete and accurate.

Right to Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you for purposes other than treatment, payment and health care operations and certain other permitted disclosures. You may request a list of the disclosures we have made in the six years before the date of your request. We may charge a nominal fee for this list if a request is made more than one time in a twelve-month period.

Right to Request Restrictions

You have the right to request restrictions or limitations on the use or disclosure of your protected health information for treatment, payment or health care operations. You may request restrictions or limitations on the disclosure of your protected health information to a family member, relative, close personal friend, or other person you identify. You may also request restrictions or limitations on the use or disclosure of your protected health information for disaster relief purposes or after your death.

We are not required to agree to your request to restrict these uses or disclosures of your protected
health information except in one circumstance: we must agree to your request to restrict disclosure of protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the information pertains solely to a health care item or service for which you or some entity other than the health plan has paid Interborough in full.

Right to Request Confidential Communications

You have the right to request that we communicate with you about mental health matters in a certain way or at a certain location. You must make this request in writing. You must specify the way you would like us to communicate with you or the location to which we will send your information in your request.

Right to a Paper Copy of this Notice

You have the right to a paper copy of this notice. To obtain a paper copy, please contact our Privacy Officer at DBA IDCC Health Services, 201 Kings Highway, Brooklyn, NY 11223.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the United States Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278. You will not be penalized for filing a complaint.

You file a complaint with us, in writing, with the Privacy Officer, DBA IDCC Health Services, 201 Kings Highway, Brooklyn, NY 11223.

Changes to this Notice

We reserve the right to change the terms of our Notice of Privacy Practices. You may obtain a copy of our current Notice of Privacy Practices by calling us at (718) 375-1200 and requesting that a copy be sent to you in the mail or by asking for one any time you are in our office