If you have any questions about this notice, please contact the Privacy Officer at 798-1487.

Our Commitment To Your Privacy:
We understand that medical information about you and your health is personal. We are committed to maintaining the privacy of your protected health information (PHI). We create a record of the care and services you receive at Slocum-Dickson Medical Group. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the medical group.

How We May Use and Disclose Your Protected Health Information:
The following categories describe different ways that we use and disclose your protected health information. For each category of uses and disclosures we will explain what we mean and give you some examples. Not every use or disclosure in a category will be listed.

For Treatment:
We may use protected health information about you to provide you with medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, healthcare students, or other personnel who are involved in taking care of you at Slocum-Dickson Medical Group. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose protected health information about you to people outside the facility who may be involved in your medical care, such as Hospice, home healthcare providers, and others we use to provide services that are part of your care.

For Payment:
We may use and disclose protected health information about you so that the treatment and services you receive at Slocum-Dickson Medical Group 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 treatment you received at Slocum-Dickson Medical Group so your health plan will pay us or reimburse you for the treatment. 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 Healthcare Operations:
We may use and disclose protected health information about you for healthcare operations. These uses and disclosures are necessary to ensure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services, and to evaluate the performance of our staff in caring for you. We may also combine medical information about our patients to decide what additional services Slocum-Dickson Medical Group should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to physicians, nurses, technicians, healthcare students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other facilities to compare how we are doing and determine where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care delivery without learning who the specific patients are.

Appointment Reminders:
We may use and disclose your protected health information to contact you and confirm a scheduled appointment.

Individuals Involved In Your Care:
We may release your protected health information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a friend may drive you to and home from our laboratory draw station. If you need to return for additional blood draws, we may have to tell your driver. Therefore, some of your protected health information may be shared.

Treatment Alternatives:
We may use and disclose protected health information 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 protected health information to tell you about health-related benefits or services that may be of interest to you.

As Required By Law:
We will disclose protected health information about you when required to do so by federal, state, or local authorities.

 

Uses and Disclosures of Your Protected
Health Information in Certain Special Circumstances:
The following categories describe unique scenarios in which we may use or disclose your protected health information.

Research:
We may use and disclose your protected health information for research purposes in certain limited circumstances. We will obtain your written authorization to use your protected health information for research purposes, except when:

•	Our disclosure was approved by an Institutional Review Board or Privacy Board
•	We obtain the oral or written agreement of a researcher that (1) the information being sought is necessary for the research study, (2) the use or disclosure of your protected health information is being used only for the research, and (3) the researcher will not remove any of your protected health information from our practice.

To Avert a Serious Threat to Health or Safety:
We may use and disclose protected health information 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 a person or organization able to help prevent the threat.

Military and Veterans:
If you are a member of the armed forces, we may release protected health information about you as required by military command authorities with your written authorization.

Workers’ Compensation:
We may release protected health information about you for Workers’ Compensation or similar programs with your written authorization. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks:
We may disclose protected health information 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. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:
We may disclose protected health information 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:
We may disclose protected health information about you in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute.

Coroners, Medical Examiners, and Funeral Directors:
We may release protected health information 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 medical information about Slocum-Dickson Medical Group patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities:
We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may also disclose your protected health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates:
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

 

Your Rights Regarding Medical Information About You:
You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy:
You have the right to inspect or obtain copies of your protected health information that may be used to make decisions about your care. All requests must be made in writing. The Correspondence Coordinator of the Medical Record Department processes requests for patient access to protected health information, and requests to send records to another health care provider for continuity of care. The phone number to call for such requests is 798-1498. If the copies are for your personal use, Slocum-Dickson Medical Group shall charge a reasonable fee, as allowed by New York State law. If a person is unable to afford such a payment, and shows proof of inability to pay, the fee will be waived. Requests for copies of medical records for disability, attorneys, and life insurance are processed by the Disability Coordinator. The phone number to call for such requests is 798-1769. Slocum-Dickson Medical Group shall have ten (10) business days to comply with all requests. We may deny your request to inspect and copy your medical information in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Slocum-Dickson Medical Group 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:
You may ask us to amend your health information if you believe it is inaccurate or incomplete. You have the right to request an amendment for as long as Slocum-Dickson Medical Group maintains the information.

To request an amendment, your request must be made in writing to our 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 your 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 medical information kept by of for the facility;
•	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 disclosures of protected health information made by Slocum-Dickson Medical Group, except for the following disclosures:
•	To carry out treatment, payment, and healthcare operations;
•	To individuals of protected health information about them;
•	Pursuant to an authorization

To request this accounting of disclosures, you must submit your request in writing to our 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. There will be no charge for the first list you request in a 12 month period. We may charge a reasonable fee for each subsequent request for an accounting by the same individual within the 12 month period. 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.

We must provide you with this list no later than 60 days after the request is received. If we are unable to provide the accounting within the time required we may extend the time to provide the accounting by no more than 30 days if we provide you with a written statement of the reasons for the delay and the date by which it will be completed.

Right to Request Restrictions:
You have the right to request a restriction in our use or disclose of your protected health information for treatment, payment, or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

To request restrictions, you must make your request in writing at one of our Reception areas. In your request, you must provide us with the following:

•	what information you want restricted;
•	whether you want to limit our practice’s use, disclosure, or both;
•	to whom you want the limits to apply

We are not required to agree to your request. If we do agree, we will comply with your request unless the restricted protected health information is needed to provide you with emergency treatment. In this case, we would disclose the information to a health care provider to provide such treatment. You have the right to terminate a restriction at any time.

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 a written request at one of our Reception areas, specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate all reasonable requests. You do not need to give a reason for your request.

Right to a Paper Copy of This Notice:
You have the right to a paper copy of this notice. You may ask us to provide you with a copy of this notice at any time. Even if you have agreed to receive a copy of this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.sdmg.com.

To obtain a paper copy of this notice, please visit any of the Reception areas within Slocum-Dickson Medical Group.

 

Changes to This Notice:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in all Slocum-Dickson Medical Group facilities. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, you may request a copy of our current notice at any time.

Complaint Process:
If an individual believes that their privacy rights have been violated, they may file a complaint with the Quality and Utilization Manager at 798-1503, or they may submit in writing a complaint to the Quality and Utilization Manager at Slocum-Dickson Medical Group, or with the Secretary of Health and Human Services. By registering this complaint, an individual can be assured that there will be no adverse consequences or retaliation.

Other Uses of Protected Health Information:
We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by law. If you provide us with permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.