Notice of Privacy Practices (HIPAA)

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.

Your Rights

When it comes to your health information, you have certain rights.

Get an electronic or paper copy of your medical record

You can ask to see or obtain an electronic or paper copy of your medical record and other health information we have about you.

We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee as permitted by law.

Ask us to correct your medical record

You can ask us to correct health information about you that you believe is incorrect or incomplete. We may deny your request in certain circumstances, but we will tell you why in writing, generally within 60 days.

Request confidential communications

You can ask us to contact you in a specific way, such as at a particular phone number or address. We will accommodate reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our health care operations. We are not required to agree to every request.

If you pay for a service or health care item out-of-pocket in full, you can ask us not to share information about that service or item with your health plan for payment or health care operations. We will honor that request unless a law requires us to share the information.

Get a list of disclosures

You can ask for an accounting of certain disclosures of your health information made during the six years before your request.

The accounting generally will not include disclosures for treatment, payment, health care operations, and certain other disclosures excluded by law.

We will provide one accounting in a 12-month period at no charge and may charge a reasonable, cost-based fee for additional requests during that period.

Get a copy of this notice

You can ask for a paper copy of this Notice at any time, even if you agreed to receive it electronically.

Choose someone to act for you

If someone has legal authority to act for you, such as through a medical power of attorney or legal guardianship, that person may exercise your rights and make choices about your health information. We will verify that person’s authority before taking action.

File a complaint if you believe your rights have been violated

You may complain to us if you believe we have violated your privacy rights by contacting us using the information at the end of this Notice.

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

You may tell us your preferences regarding:

• sharing information with family members, close friends, or others involved in your care;
• sharing information in a disaster-relief situation;
• certain communications permitted by law.

If you are unable to tell us your preference, we may share information when permitted by law if we believe doing so is in your best interest. We may also share information when necessary to lessen a serious and imminent threat to health or safety.

We will obtain your written authorization when required by law, including for:

• most uses and disclosures of psychotherapy notes;
• certain marketing activities;
• The sale of protected health information.

If you give us written authorization, you may revoke it in writing at any time, except to the extent that we have already acted in reliance on your authorization.

How We Typically Use and Share Your Health Information

Treatment

We can use your health information and share it with other health professionals who are treating you. For example, a clinician treating you may share relevant health information with another health professional involved in your care.

Health Care Operations

We can use and share your health information to operate our practice, improve the quality of care, coordinate services, and contact you when necessary.

Payment

We can use and share your health information to bill and obtain payment from health plans and other responsible parties. For example, we may provide information to your health insurance plan so that it can determine coverage or pay for services.

Other Uses and Disclosures

We may use or disclose your health information without your written authorization when permitted or required by law, including for:

• public health and safety activities;
• reporting suspected abuse, neglect, or domestic violence when required or permitted by law;
• preventing or reducing a serious threat to health or safety;
• health oversight activities;
• health research when permitted by law;
• workers’ compensation matters;
• certain law-enforcement purposes;
• judicial and administrative proceedings when legal requirements are satisfied;
• medical examiners, coroners, and funeral directors;
• organ and tissue donation activities when applicable;
• certain government functions;
• other uses or disclosures required by law.

Mental Health Information and Psychotherapy Notes

Mental health information may receive additional protection under federal or New York law. We will use and disclose mental health information only as permitted by applicable law.

Psychotherapy notes receive special protection under HIPAA. Most uses and disclosures of psychotherapy notes require your written authorization except where otherwise permitted or required by law.

Substance Use Disorder Records

Certain substance use disorder patient records may receive additional protection under 42 CFR Part 2. To the extent we create, receive, or maintain substance use disorder patient records protected by Part 2, we will use and disclose those records in accordance with applicable HIPAA and Part 2 requirements. Part 2 records, or testimony describing the content of those records, generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide written consent or the applicable requirements for a Part 2 court order and subpoena or similar legal mandate are satisfied. If we use Part 2 information for fundraising communications, when applicable, you will receive advance notice and an opportunity to opt out as required by law.

Our Responsibilities

We are required by law to:

• maintain the privacy and security of your protected health information;
• notify you following a breach when required by law;
• provide you with this Notice describing our legal duties and privacy practices;
• follow the duties and privacy practices described in the Notice currently in effect;
• refrain from using or disclosing your health information except as described in this Notice or as otherwise permitted or required by law.

When your written authorization is required, you may revoke that authorization in writing at any time, except to the extent we have already acted in reliance upon it.

Changes to This Notice

We may change the terms of this Notice and make the revised Notice effective for health information we already maintain as well as information we receive in the future.

If we make a material change, the revised Notice will be made available on our website and as otherwise required by law.

Questions or Complaints

If you have questions about this Notice, want additional information about our privacy practices, or want to make a privacy complaint, contact:

Privacy Contact

Eastview Medical Psychiatry PLLC d/b/a Orlin Mental Health

201 Bryson Ave Staten Island, NY 10314

Phone: (917) 920-7650

Email: office@orlinmentalhealth.com

You may also file a complaint with:

U.S. Department of Health and Human Services

Office for Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

Phone: 1-877-696-6775

We will not retaliate against you for filing a complaint.