A medical record is a confidential document and access to it generally is limited to the patient or an authorized representative, the attending physician, and health care professionals possessing legitimate interest in the record relating to the patient's care.

Prime Columbia Greene Medical Associates, PC (PCGMA) owns its patient's records and has the obligation to respect the pertinent rules of confidentiality and access with respect to the information the record contains. In most cases, the patient's written authorization is required before records of any kind can be released.

The rules contain exceptions for access by persons other than the patient, typically, health care professionals and the patient's medical facility personnel, insurance carrier, employer or health services plan as required for billing purposes. Another typical exception is a legal proceeding such as responding to a subpoena.

Our group is committed to safeguarding the confidential information of our clients. We hold all personal data provided to us in the strictest confidence. Indeed, we require your specific permission before we will discuss your affairs with anyone other than those named above.

PCGMA considers the privacy of its patients to be of fundamental importance and has established a policy to maintain the privacy of the information you share with us.

The security measures practiced by PCGMA reflect our commitment to maintaining the privacy of your confidential information. We appreciate the confidence you have shown in our ability to serve your health needs, and want you to also know that your personal records are safe with us.

Notice of Information Practices

THIS NOTICE DESRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

*Understanding Your Prime Columbia Greene Medical Associates, PC Health Record Information*

Each time you visit a hospital, a physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to as your medical record, serves as the following:

• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care that you received
• Means by which you or a third-party payer can verify that you actually received the services billed for
• Tool in medical education
• Source of information for public health officials charged with improving the health of the regions they serve
• Tool to assess the appropriateness and quality of the care that you received
• Tool to improve the quality of health care and achieve better patient outcomes

Understanding what is in your health records and how your health information is used helps you to:

• Ensure its accuracy and completeness
• Understand who, what, where, why and how others may access your health information
• Make informed decisions about authorizing disclosure to others
• Better understand the health information rights detailed below
• Realize that mental health history may be included.

*Your rights under the Federal Privacy Standard*

Although your health records are the physical property of the health care provider who completed it, you have the following rights with regard to the information contained therein:

• Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. "Health care operations" consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under the following section of the federal privacy regulations: § 164.50(a)(2)(i) (disclosures to you), or 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory communicable disease reporting. In those cases, you do not have a right to request restriction. We do not, however, have to agree to the restriction. If we do we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is reasonable, we must grant the alternate communication request. You may request restriction or alternate communications on the consent form for treatment, payment, and health care operations.
• Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our web site (pcgma.com), you have a right to a hard copy upon request.
• Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
  • Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, join, or family counseling session and that are separated from the rest of your medical record.
  • Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
  • Protected health information ("PHI") that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C. § 263a, to the extent that giving you access would be prohibited by law.
  • Information that was obtained from someone other than a health care provider under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.
• In other situations, we may deny you access, but if we do, we must provide you a review of our decision denying access. These "reviewable" grounds for denial include the following:
  • A licensed healthcare professional, such as your attending physician, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or another person.
  • PHI makes reference to another person (other than a health care provider) and a licensed health care provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
  • The request is made by your personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that giving access to such personal representative is reasonably likely to cause substantial harm to you or another person.
• For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review. If we grant access, we will tell you what, if anything, you have to do to get access.

We reserve the right to charge a reasonable, cost-based fee for making copies.

• Request amendment/correction of your health information. We do not have to grant the request if the following conditions exist:
  • We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.
  • The records are not available to you as discussed immediately above.
  • The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom you identify to us that you want to receive the corrected information.

• Obtain an accounting of non-routine uses and disclosures, those other than for treatment, payment, and health care operations. We do not need to provide an accounting for the following disclosures:
  • To you for disclosures of protected health information to you
  • For the facility directory or to persons involved in your care or for other notification purposes as provided in § 164.510 of the federal privacy regulations (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of the location, general condition, or death)
  • For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object.)
  • That occurred before April 14, 2003.
• We must provide the accounting within 60 days. The accounting must include the following information:
  • Date of each disclosure.
  • Name and address of the organization or person who received the protected health information.
  • Brief description of the information disclosed.
  • Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.

• Revoke your consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.

Our Responsibilities under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the following measures:

• Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
• Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.
• Abide by the terms of this notice.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF WE CHANGE OUR INFORMAITON PRACTICES, WE WILL MAIL A REVISED NOTICE TO THE ADDRESS THAT YOU HAVE GIVEN US.

• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies with regard thereto.
• Mitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

How to Get More Information or Report a Problem

If you have questions and/or would like additional information, you may contact Tamton Mustapha, MD, Medical Director, at (518) 828 - 7188.

Examples of Disclosures for Treatment, Payment, and Health Operations

• Under the regulatory authority of the Department of Health and Human Services we will use your health information for treatment. Example: A physician's assistant, a therapist or a counselor, a nurse, or another member of your health care team will record information in your record to diagnose your condition and determine the best course of treatment for you. The primary caregiver will give treatment orders and document what he or she expects other members of the health care team to do to treat you. Those other members will then document the actions they took and their observations. In that way, the primary caregiver will know how you are responding to treatment. We will also provide other health care professionals, or a subsequent health care provider, copies of your records to assist them in treating you once we are no longer treating you.
• Under the regulatory authority of the Department of Health and Human Services we will use your health information for treatment. Example: We may send a bill to you or a third party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received and supplies used.
• Under the regulatory authority of the Department of Health and Human Services we will use your health information for health operations. Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality assurance team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the health care and services that we provide.
• Business associates: We provide some services through contracts with business associates. Examples include certain diagnostic tests, a copy service to make copies of medical records, and the like. When we use these services, we may disclose your health information to the business associates so that they can perform the function(s) that we have contracted with them to do and bill you or your third-party payer for services provided. To protect your health information, however, we require the business associates to appropriately safeguard your information.
• Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify health information relevant to that person's involvement in your care or payment related to your care.
• Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to enable them to carry out their duties.
• Marketing/continuity of care: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Other than appointment reminders, we will not contact you for marketing purposes without your authorization.
• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
• Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
• Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
• Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
• Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public, they may disclose your information to health oversight agencies and/or public health authorities, such as the department of health.
• The Federal Department of Health and Human Services ("DHHS"): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.
• Employers: When notifying your employer about absenteeism or a certificate to return to work, your health history may be included.

Effective date: 09.05.2002

Name of entity: Prime Columbia Greene Medical Associates, PC