Queens-Long Island Medical Group, PC (QLIMG) is committed to protecting the privacy of your health information. This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This notice is effective as of April 14, 2003.

If you have any questions about this notice, please contact us at: 1 (800) 861 - 5598.

Uses and Disclosures of Your Health Information

This section of the notice explains how QLIMG shares your health information among our employees, with our business associates and with other organizations when required. We require our business associates to protect the privacy of your health information through written agreements. As explained below, in some instances we will request your written permission to use or disclose your health information.

Uses and disclosures related to treatment, payment and healthcare operations. Your health information may be shared between our QLIMG employees or with our business associates for activities related to your treatment, payment for your care or healthcare operations at QLIMG. In these instances, QLIMG requests your consent (but is not required to obtain) your consent at the time of registration as a condition of your treatment. As described in the next section, you have the right to request a restriction on the use and disclosure of your health information for purposes of treatment, payment or healthcare operations. Following are some examples of how your health information may be used in such activities:

• Examples of activities related to treatment include: creation and maintenance of medical records, providing treatment orders instructions to patient care staff, and obtaining consultations and diagnostic and therapeutic services from specialist physicians and other providers;
• Examples of activities related to payment include: submitting bills and health care claims to payer organizations, verifying your eligibility for health plan coverage, submitting clinical information to payers to demonstrate medical necessity for treatments or procedures, and collection of amounts owed.
• Examples of activities related to healthcare operations include: quality improvement, fraud and abuse prevention and detection, medical review, and complaint resolution.

Required disclosures that do not require your written permission. Your health information may be disclosed to government agencies or other organizations without your written consent or authorization in the following circumstances: when required by law; for public health activities; about victims of abuse, neglect, or domestic violence; for health oversight activities (including audits, investigations, and inspections); for judicial and administrative proceedings; for law enforcement purposes; about deceased persons to coroners, health examiners, and funeral directors; to avert a serious threat to health or safety; for specialized government functions (such as military personnel, and inmates in correctional facilities); and for worker’s compensation.

Uses and disclosures that require your written permission. In all other circumstances, uses and disclosures of your health information will only be made with your written authorization. You may revoke such an authorization at any time.

Other uses and disclosures: We may contact you to remind you of appointments or to refill a medication. We also may use your health information to inform you about treatment alternatives or other health services that may be of interest to you.

We may disclose your health information to the benefits administrator of your employer. Your employer’s health benefits administrator is prohibited from sharing this information with your employer for purposes of employment-related decisions.

Your Privacy Rights

This section of the notice describes your rights with respect to your health information and a brief description of how you may exercise these rights.

Right to Restrict Further Uses and Disclosures for Purposes of Treatment, Payment or Healthcare Operations. You have the right to request that we restrict further uses and disclosure of your health information for activities related to treatment, payment or operations as described above. Your request for the restriction must be in writing. QLIMG will evaluate all requests for restrictions, however, we may not agree to the restriction. If we agree to the restriction, we will abide by it except in emergencies. We may terminate our agreement to a restriction with your approval or if you request the termination of the restriction. If QLIMG decides to terminate its agreement to the restriction, we will notify you of our decision.

Right to Request Confidential Communications. You may request that we communicate with you by alternative means or at alternative locations. For example, you may inform us that you wish to receive communications from us at your work location rather than your home. You must make your request to QLIMG in writing, and we will accommodate any reasonable request.

Right to Access, Inspect and Obtain Copies of Your Health Information. You have the right to access, inspect and obtain copies of your health information for as long as QLIMG maintains the information. (Note: this right does not extend to psychotherapy notes or information compiled for criminal, civil or administrative actions or proceedings.) You must make your request for access in writing, and we will act on your request within 30 days of receiving your request if the information is maintained and accessible on-site, or within 60 days otherwise (with a possible 30-day extension). We may provide you with a summary of the health information requested if you agree in advance to the summary and to any fees we may impose for preparation of the summary.

We may deny your request for access to you health information under certain circumstances, such as when access could endanger the life or safety of you or others. If your request is denied, we will send you a written denial that explains our reason for the denial, your review rights if any, and how to file a complaint with QLIMG or the Secretary of the Department Health and Human Services (DHHS).

If your request for access is denied, in certain instances we will provide you with an opportunity for review of the denial of access. The review decision must be made in a reasonable period of time, and we will provide you with a written notice of the review decision.

We will charge a fee of $.75 per page and, if requested information is mailed, the cost of postage for providing you with copies of your health information. This fee is based on our copying, mailing and summary preparation costs.

Right to Amend Your Health Information. You have the right to request that we amend your health information if you believe the information is incorrect or inaccurate. We may deny your request to amend your health information if we did not create the health information, if the information is not part of our records, if the information was not available for inspection or the information is accurate and complete.

We will respond to your written request to amend your health information within 60 days of the request (with a possible 30-day extension).

If your request for amendment is granted, we will notify you that amendment was accepted and obtain your identification of and agreement to inform relevant persons. We will make reasonable efforts to inform and provide the amendment within a reasonable time to persons identified by you and by us, including our business associates.

If your request for the amendment is denied, we will provide you with a timely, written notice which explains the reason for the denial, your right to submit a written statement of disagreement or to have the request for amendment included with future disclosures, and your right to complain to QLIMG or the Secretary of HHS. We may prepare a rebuttal statement to your statement of disagreement. We will provide you with a copy of the rebuttal statement. Any future disclosures of your health information will include the statement of disagreement or request for amendment, the denial notice, and the rebuttal or summary of this information.

Right to An Accounting of Disclosures. You have the right to receive a list or accounting of the disclosures of your health information made during a period of up to six years prior to the date of your request. We will act on your request for an accounting of disclosures within 60 days (with a possible 30-day extension). This accounting of disclosures will not include the following disclosures:

• For treatment, payment and operations
• Made by us to you
• For national security or intelligence purposes
• To correctional institutions or law enforcement officials
• Disclosures made prior to April 14, 2003.

We will provide you with one free accounting each year. The written accounting of disclosures will include the following information for each disclosures: the date of the disclosure, the person to whom the information was disclosed, a brief description of the information disclosed or in lieu of the summary, a copy of the authorization or request for disclosure.

Right to A Copy of Privacy Notice. You have the right to receive a paper copy of this notice upon request, even if you agreed to receive the notice electronically.

Complaints. You may complain to QLIMG or the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint with QLIMG, contact 1-866-FILES MD -(866-345-3763). . We will not intimidate, discriminate against, or retaliate against you if you exercise any right or process described in this notice, including the filing of a complaint or testifying, assisting, or participating in an investigation, compliance review, or hearing.

Our Responsibilities

QLIMG is required by a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state laws to maintain the privacy of your health information and to provide you with this notice of privacy practices. QLIMG will abide by the terms of this notice of privacy practices.

Changes to Our Privacy Practices

QLIMG will publish a revised privacy notice whenever we make significant changes in our policies for use and disclosure, individual privacy rights, our responsibilities or any other practices described in this notice. While QLIMG reserves the right to implement changes its privacy practices without prior notice, we will make a revised notice available on request. QLIMG also reserves the right to apply any changes in its policies and procedures to all health information maintained by QLIMG, regardless of when received.