SIMHS Notice of Privacy Practices*
*It
is the policy of the Staten Island Mental Health Society that we
do not collect personal information from visitors to this website.
HIPAA for Minors
Health Insurance Portability and Accountability Act for Minors
Staten Island Mental Health Society, Inc.
Notice of Privacy Practices
Effective: April 14, 2003
This notice describes
how personal information about your child and family may be used
and disclosed and how you can access this information. Please review
it carefully.
© SIMHS, Inc., 2003
What Is Personal Information?
When you come to the Staten Island Mental Health Society, Inc.
for care for your child, we will ask for personal information such
as:
- Your child's name, address, and telephone number
- Information about your child's medical history
- Information about your child's health insurance
- Information about other doctors or healthcare providers who
treated your child in the past, or are currently treating your
child
- Information regarding others to contact in case of emergency
- Information regarding education
- Family information
We also gather personal information about your child and family
when we treat your child. We may get information about your child
from others who are part of your child's "circle of care"
such as your child's physician, other therapists or providers who
have treated your child, healthcare facilities that have provided
treatment to your child, your child's health insurance plan, and
sometimes even family members or close friends who help take care
of your child. We always create a record of the information we collect,
the health findings we make and the care we provide to your child.
We also have records of the bills that we send you and your insurer
for your child's care.
Privacy Promise
Staten Island Mental Health Society, Inc. (SIMHS) understands
that your child's and family's personal information needs to be
kept private. Protecting your child's and family's personal information
is important. We follow strict federal and state laws that require
us to keep personal information confidential.
How We Use Your Child's and Family’s Personal Information
When your child receives services from SIMHS, we may use your
child's and family's personal information for such activities as
providing your child with services, billing for services, and conducting
our normal business known as health care operations.
If you have chosen a personal representative and have agreed to
let your child's personal representative obtain your child's and
family's personal information, we will provide the information to
your child's personal representative. If your child has a guardian,
we will provide the information to your child's guardian.
Examples of how we use your child's information include:
Treatment
We keep records of the care and services provided to your child
within SIMHS. For example, your child's therapist keeps notes
on all contacts made in providing, coordinating and arranging
for services. SIMHS staff may share your child's and family's
personal information while helping to develop your child's treatment
plan.
Except for certain circumstances detailed on page two of this
document, if SIMHS staff want to share your child's or family's
personal information with anyone who is not employed by SIMHS,
you must give them written permission first.
Some personal records, including confidential communications
with a mental health professional, substance abuse records, and
HIV/AIDS information may have additional restrictions for use
and disclosure under state and federal law.
If the New York State laws regarding alcohol and drug treatment
records, records concerning the treatment of a minor patient for
venereal disease or the performance of an abortion, restrictions
on disclosure of information that would have a detrimental effect
on a therapist's professional relationship with a minor (or on
the minor's relationship with his or her parent) and confidential
HIV information are stricter than Federal laws, then New York
State law will prevail.
Payment
We keep records that include payment information and documentation
of the services provided to your child. This information may be
used to obtain payment for your child's services from Medicaid,
or other sources. For example, we may disclose personal information
about the services provided to your child to confirm eligibility
for Medicaid and to obtain payment from Medicaid. SIMHS may use
your child's personal information to determine the amount and
type of Medicaid services your child needs and send this information
to the proper state department.
Health Care Operations
We use personal information to improve the quality of care, train
staff, manage costs, conduct required business duties, and make
plans to better serve your child and other individuals who receive
services from SIMHS. For example, we may use your child's and
family's personal information to evaluate the quality of treatment
and services provided by our service staff.
Fundraising - We may use aggregate grouped data, that includes
demographic information about your child and family in order to
support our business operations. Your child will not be individually
identified.
Business Associates - We sometimes work with individuals and businesses
that help us operate our business successfully. We may disclose
personal information about your child and family to these business
associates if they need it to perform the tasks that we hire them
to do. To protect your child's health information, we always include
a provision in our contracts with our business associates requiring
them to put procedures in place to safeguard the confidentiality
of our patients' health information. Examples of our business
associates include consultants that we hire to help us ensure
our compliance with applicable federal, state, and local laws,
our lawyers, and our accountants.
Persons Assisting in the Patient's Care
We may disclose information about your child to individuals involved
in your child's care or in the payment of your child's care. This
includes people that are part of your child's "circle of
care"—such as you and/or your spouse, or a friend or
aide who is helping with your child's care or with your child's
bills. We also may use and disclose health information about your
child for disaster relief efforts and to notify persons responsible
for your child's care about your child's location, general condition
or death.
Generally, we will obtain your verbal permission before using
or disclosing your child's health information for these purposes.
However, under certain circumstances, such as in an emergency,
we may make these uses and disclosures without your agreement.
Other Services We Provide
We may also use your child's and family's personal information
to:
- determine whether your child is eligible for services from
SIMHS.
- recommend to your child service alternatives and other possible
benefits.
- tell you about other service providers who may be able to help
your child.
- remind you of an appointment unless you tell SIMHS staff that
you do not wish to be reminded.
- allow SIMHS to review direct service contracts.
- allow local, state and federal agencies to monitor your child's
services.
- investigate incidents affecting health and safety, to report
these kinds of incidents and to take steps to protect your child's
health and safety.
- allow SIMHS to prepare reports required by the New York State
Office of Mental Retardation and Developmental Disabilities, the
New York State Office of Mental Health, the New York State Office
of Alcoholism and Substance Abuse Services, the New York City
Department of Health and Mental Hygiene and other funding or monitoring
bodies.
Sharing Your Child's Personal Information
There are limited situations where we are permitted or required
to disclose personal information without your signed authorization.
These situations are:
- to protect suspected victims of abuse, neglect, or violence.
- to reduce or prevent a possible serious threat to public health
and safety.
- for health oversight activities such as investigations, audits,
and inspections.
- for lawsuits and similar proceedings.
- for public health purposes such as reporting communicable diseases,
work-related illnesses, or other diseases and injuries permitted
by law; reporting births and deaths, and reporting reactions to
drugs and problems with medical devices.
- when required by law.
- when requested by authorized law enforcement as required by
law or court order.
- to coroners, medical examiners, and funeral directors.
- for Workers' Compensation or other similar programs if you are
injured at work and are covered by Workers' Compensation or other
similar programs.
- for specialized government functions such as intelligence and
national security.
- for research, with your consent, or when a review board has
approved research which poses minimal risk and your child's privacy
is ensured. No public disclosure of your child's name will be
made without your consent.
All other uses and disclosures, not described in this notice,
require your signed authorization. You may revoke your authorization
at any time with a written statement.
Who Will Follow This Notice?
All SIMHS employees, consultants, interns, volunteers, and business
associates.
Our Privacy Responsibilities
SIMHS is required by law to:
- maintain the privacy of your child's personal information.
- provide this notice that describes the ways we may use and share
your child's personal information.
- follow the terms of the notice currently in effect.
We reserve the right to make changes to this notice at any time
and make the new privacy practices effective for all information
we maintain.
Current notices will be posted in all SIMHS facilities. You may
also request a copy of any notice from the SIMHS Privacy Officer.
Your Child’s Individual Rights
You have the right to:
- request restrictions on how we use and share your child's personal
information. We will consider all requests for restrictions carefully,
but are not required to agree to any restriction.*
- request that we use a specific telephone number or address to
communicate with you.
- inspect and copy your child's personal information, including
service, medical and billing records. Fees may apply.*
- request corrections or additions to your child's personal information.*
- request an accounting of certain disclosures of your child's
personal information made by us. Your request must state the period
of time desired for the accounting, which must be within the six
years prior to your request. The first accounting is free, but
a fee will apply if more than one request is made in a 12-month
period.*
- request a paper copy of this notice even if you agree to receive
it electronically.
Requests marked with a star (*) must be made in writing. Contact
the SIMHS Privacy Officer for the appropriate form for your request.
Our Organization
This notice describes the privacy practices of the Staten Island
Mental Health Society, Inc. (SIMHS). This notice also describes
the privacy practices of persons or entities which have signed a
contract with SIMHS and which are acting as business associates,
and have promised to follow the same rules of confidentiality.
If you want to know about the privacy practices of service providers
who are not employed by the SIMHS and who are not business associates,
you should contact them directly.
Contact Us
If you would like further information about your child's privacy
rights, are concerned that your child's privacy rights have been
violated, or disagree with a decision that we made about access
to your child's personal information, please contact SIMHS's Privacy
Officer:
Michael Skinner, CSW
Staten Island Mental Health Society, Inc.
669 Castleton Avenue
Staten Island, New York 10301
Tel: (718) 442-2225
Fax: (718) 442-2289
How To File A Complaint
To file a complaint with us, please contact:
Michael Skinner, CSW, Privacy Officer
Staten Island Mental Health Society, Inc.
669 Castleton Avenue
Staten Island, New York 10301
(718) 442-2225.
We will investigate all complaints and will not retaliate against
you for filing a complaint.
You also may file a written complaint with either:
The Secretary of the U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C., 20201
or call 1-877-696-6775
or
The Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 509F, HHH Building
Washington, D.C., 20201
or call OCR's hotline—voice at 1-800-368-1019
or e-mail at ocrmail@hhs.gov.
In addition, the Federal Center for Deaf and Hearing Impaired
can be contacted at 1-800-877-8339.
It should be noted that the SIMHS will not retaliate or penalize
the parent/legal guardian or patient for filing a complaint.
HIPAA for Adults
Health Insurance Portability and Accountability Act for Adults
Staten Island Mental Health Society, Inc.
Notice of Privacy Practices
Effective: April 14, 2003
This notice describes
how personal information about you may be used and disclosed and
how you can access this information. Please review it carefully.
© SIMHS, Inc., 2003
*What Is Personal Information?
When you come to the Staten Island Mental Health Society, Inc.
for care for you, we will ask for personal information such as:
- Your name, address, and telephone number
- Information about your medical history
- Information about your health insurance
- Information about other doctors or healthcare providers who
treated you in the past, or are currently treating you
- Information regarding others to contact in case of emergency
- Information regarding education
- Family information
We also gather personal information about you and your family
when we treat you. We may get information about you and your family
from others who are part of your "circle of care" such
as your physician, other therapists or providers who have treated
you, healthcare facilities that have provided treatment to you,
your health insurance plan, and sometimes even family members or
close friends who help take care of you. We always create a record
of the information we collect, the health findings we make and the
care we provide to you. We also have records of the bills that we
send you and your insurer for your care.
Privacy Promise
Staten Island Mental Health Society, Inc. (SIMHS) understands
that your and your family's personal information needs to be kept
private. Protecting your and your family's personal information
is important. We follow strict federal and state laws that require
us to keep your and your family's personal information confidential.
How We Use Your and Your Family's Personal Information
When you receive services from SIMHS, we may use your and your
family's personal information for such activities as providing you
with services, billing for services, and conducting our normal business
known as health care operations.
If you have chosen a personal representative and have agreed to
let your personal representative obtain your and your family's personal
information, we will provide the information to your personal representative.
Examples of how we use your information include:
Treatment
We keep records of the care and services provided to you within
SIMHS. For example, your therapist keeps notes on all contacts
made in providing, coordinating and arranging for services. SIMHS
staff may share your and your family's personal information while
helping to develop your treatment plan.
Except for certain circumstances detailed on page two of this
document, if SIMHS staff want to share your and your family's
personal information with anyone who is not employed by SIMHS,
you must give them written permission first.
Some personal records, including confidential communications
with a mental health professional, substance abuse records, and
HIV/AIDS information may have additional restrictions for use
and disclosure under state and federal law.
If the New York State laws regarding alcohol and drug treatment
records, records concerning the treatment of a minor patient for
venereal disease or the performance of an abortion, restrictions
on disclosure of information that would have a detrimental effect
on a therapist's professional relationship with a minor (or on
the minor's relationship with his or her parent) and confidential
HIV information are stricter than Federal laws, then New York
State law will prevail.
Payment
We keep records that include payment information and documentation
of the services provided to you. This information may be used
to obtain payment for your services from Medicaid, or other sources.
For example, we may disclose personal information about the services
provided to you to confirm eligibility for Medicaid and to obtain
payment from Medicaid. SIMHS may use your and your family's personal
information to determine the amount and type of Medicaid services
you need and send this information to the proper state department.
Health Care Operations
We use personal information to improve the quality of care, train
staff, manage costs, conduct required business duties, and make
plans to better serve you and other individuals who receive services
from SIMHS. For example, we may use your personal information
to evaluate the quality of treatment and services provided by
our service staff.
Fundraising
We may use aggregate grouped data, that includes demographic
information about you in order to support our business operations.
You will not be individually identified.
Business Associates
We sometimes work with individuals and businesses that help us
operate our business successfully. We may disclose personal information
about you to these business associates if they need it to perform
the tasks that we hire them to do. To protect your health information,
we always include a provision in our contracts with our business
associates requiring them to put procedures in place to safeguard
the confidentiality of our patients' health information. Examples
of our business associates include consultants that we hire to
help us ensure our compliance with applicable federal, state,
and local laws, our lawyers, and our accountants.
Persons Assisting in the Patient's Care
We may disclose information about you and your family to individuals
involved in your care or in the payment of your care. This includes
people who are part of your "circle of care"—such
as you and/or your spouse, or a friend or aide who is helping
with your care or with your bills. We also may use and disclose
health information about you for disaster relief efforts and
to
notify persons responsible for your care about your location,
general condition or death.
Generally, we will obtain your verbal permission before using
or disclosing your health information for these purposes. However,
under certain circumstances, such as in an emergency, we may make
these uses and disclosures without your agreement.
Other Services We Provide
We may also use your personal information to:
- determine whether you are eligible for services from SIMHS.
- recommend to you service alternatives and other possible benefits.
- tell you about other service providers who may be able to help
you.
- remind you of an appointment unless you tell SIMHS staff that
you do not wish to be reminded.
- allow SIMHS to review direct service contracts.
- allow local, state and federal agencies to monitor your services.
- investigate incidents affecting health and safety, to report
these kinds of incidents and to take steps to protect your health
and safety.
- allow SIMHS to prepare reports required by the New York State
Office of Mental Retardation and Developmental Disabilities, the
New York State Office of Mental Health, the New York State Office
of Alcoholism and Substance Abuse Services, the New York City
Department of Health and Mental Hygiene and other funding or monitoring
bodies.
Sharing Your Personal Information
There are limited situations where we are permitted or required
to disclose personal information without your signed authorization.
These situations are:
- to protect suspected victims of abuse, neglect, or violence.
- to reduce or prevent a possible serious threat to public health
and safety.
- for health oversight activities such as investigations, audits,
and inspections.
- for lawsuits and similar proceedings.
- for public health purposes such as reporting communicable diseases,
work-related illnesses, or other diseases and injuries permitted
by law; reporting births and deaths, and reporting reactions to
drugs and problems with medical devices.
- when required by law.
- when requested by authorized law enforcement as required by
law or court order.
- to coroners, medical examiners, and funeral directors.
- for Workers' Compensation or other similar programs if you are
injured at work and are covered by Workers' Compensation or other
similar programs.
- for specialized government functions such as intelligence and
national security.
- for research, with your consent, or when a review board has
approved research which poses minimal risk and your privacy is
ensured. No public disclosure of your name will be made without
your consent.
All other uses and disclosures, not described in this notice,
require your signed authorization. You may revoke your authorization
at any time with a written statement.
Who Will Follow This Notice?
All SIMHS employees, consultants, interns, volunteers, and business
associates.
Our Privacy Responsibilities
SIMHS is required by law to:
- maintain the privacy of your personal information.
- provide this notice that describes the ways we may use and share
your personal information.
- follow the terms of the notice currently in effect.
We reserve the right to make changes to this notice at any time
and make the new privacy practices effective for all information
we maintain.
Current notices will be posted in all SIMHS facilities. You may
also request a copy of any notice from the SIMHS Privacy Officer.
Your Individual Rights
You have the right to:
- request restrictions on how we use and share your personal
information. We will consider all requests for restrictions carefully,
but are not required to agree to any restriction.*
- request that we use a specific telephone number or address to
communicate with you.
- inspect and copy your personal information, including service,
medical and billing records. Fees may apply.*
- request corrections or additions to your personal information.*
- request an accounting of certain disclosures of your personal
information made by us. Your request must state the period of
time desired for the accounting, which must be within the six
years prior to your request. The first accounting is free, but
a fee will apply if more than one request is made in a 12-month
period.*
- request a paper copy of this notice even if you agree to receive
it electronically.
Requests marked with a star (*) must be made in writing.
Contact the SIMHS Privacy Officer for the appropriate form for your
request.
Our Organization
This notice describes the privacy practices of the Staten
Island Mental Health Society, Inc. (SIMHS). This notice also
describes the privacy practices of persons or entities which
have signed a contract with SIMHS and which are acting as business
associates, and have promised to follow the same rules of confidentiality.
If you want to know about the privacy practices of service providers
who are not employed by the SIMHS and who are not business associates,
you should contact them directly.
Contact Us
If you would like further information about your privacy rights,
are concerned that your privacy rights have been violated, or
disagree with a decision that we made about access to your personal
information, please contact SIMHS's Privacy Officer:
Michael Skinner, CSW
Staten Island Mental Health Society, Inc.
669 Castleton Avenue
Staten Island, New York 10301
Tel: (718) 442-2225
Fax: (718) 442-2289
How To File A Complaint
To file a complaint with us, please contact:
Michael Skinner, CSW, Privacy Officer
Staten Island Mental Health Society, Inc.
669 Castleton Avenue, Staten Island, New York 10301
(718) 442-2225
We will investigate all complaints and will not retaliate
against you for filing a complaint.
You also may file a written complaint with either:
The Secretary of the U.S. Department of Health and Human
Services
200 Independence Avenue, S.W.
Washington, D.C., 20201
or call 1-877-696-6775
or
The Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 509F, HHH Building
Washington, D.C., 20201
or call OCR's hotline - voice at 1-800-368-1019
or e-mail at ocrmail@hhs.gov.
In addition, the Federal Center for Deaf and Hearing Impaired
can be contacted at 1-800-877-8339.
It should be noted that the SIMHS will not retaliate or penalize
the parent/legal guardian or patient for filing a complaint.
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