Notice of American Indian Health Program Privacy Practices
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.
The American Indian Health Program provides many different services to you. It provides health care, it pays for health care, processes bills, and supervises the health facilities. All health information in our possession is maintained confidentially by the program. We are required by law to provide you with this notice of privacy practices to let you know how your health information is used and disclosed. We are required to notify you should a breach of your information occur.
Your Health Information Rights:
You have a right to have your health information kept confidential. You, or a person legally authorized to act for you (e.g., parents of a minor, guardian, a health care proxy), have a right to:
- get a paper copy of this notice of privacy practices upon request;
- see or get a copy of your health information for a reasonable fee; if denied, you have the right to seek a review of the denial;
- request amendments to your health information;
- request limits on certain uses and disclosures of your information;
- get a list of disclosures of your health information;
- request communications of your health information by alternative means or at alternative locations;
- revoke any special authorizations in writing to use or disclose health information, except to the extent that disclosure has already been taken.
You can exercise your rights by contacting the American Indian Health Program Manager at (518) 474-6968 or by writing to: American Indian Health Program Manager, New York State Department of Health, Division of Family Health, Corning Tower, Room 890, Albany, New York 12237.
NOTE: Special rules apply which restrict access to psychotherapy notes, HIV/AIDS information and federally protected drug and alcohol information. See any special authorizations or consent forms which will specify what information may be released and when, or contact the person listed above.>
What Are Our Responsibilities to You?
We must maintain the privacy of your health information, and give you this notice that tells you how we will keep your health information private. We must tell you if we are unable to agree to a limit on use or disclosure which you request. By law the American Indian Health Program must have your written permission to use or give out your personal medical information for any purpose that is not set out in this notice. We will carry out reasonable requests to communicate health information to you by special means or at other locations and get your written permission to use or disclose health information in ways other than those set out in this notice. We have the right to change our practices regarding the health information we keep. If practices are changed, we will tell you by sending a new notice to the head of your nation and the clinic who will distribute the new notice to you. Notices will be posted on the New York State Department of Health website at http://www.health.ny.gov.
How Does the Program Use or Disclose Your Health Information?
For Treatment: With your permission, information is used and disclosed to provide you with medical services. For example, a doctor may consult and share information with an off-site specialist to whom you have been referred for care.
For Payment: You may authorize the program to use and disclose your health information to others (for example, your insurance company or Medicaid) to receive payment for services rendered.
For Health Care Operations: Health information is used and disclosed for operational reasons. For example, your information may be used to assess the quality of care provided to you or others, to improve services and facilities, or to train and evaluate staff.
For Appointments and Health Related Benefits: With your permission, the program may use and disclose information for appointment reminders, or information about treatment alternatives and benefits.
For Disclosures to Friends and Family: The program may disclose your health information to friends and family who are involved in your care, with appropriate consent. For example, if you request that the information be shared with a specific family member.
For Eligibility Determination: Information is disclosed to the governing body of your nation, or their designee, to determine eligibility for enrollment in the American Indian Health Program. For example, your name and date of birth may be submitted to verify eligibility.
In certain other situations, the program can use and disclose information without your authorization:
For Serious Threats to Health and Safety: Your health information may be disclosed to avert a serious threat to public health and safety, as permitted by law.
If Required by Law or for Law Enforcement: The program may use and disclose information as required by law. For example, for the mandatory reporting of child abuse and neglect, for domestic violence, for judicial or administrative proceedings if required by legal process, for certain law enforcement purposes (e.g., to aid in locating a fugitive, or a missing person), for workers compensation and for similar programs established by law.
For Public Health Reasons: The program may use or disclose information for required public health activities such as controlling disease or injury (for example, lead screening).
For Health Oversight Reasons: Information may be disclosed when required to monitor the level and quality of care you receive.
For a Contracted or Affiliated Purpose: Our contractors, agents and partners may be given health information if necessary for them to perform certain services for us. For example, the program may share information with companies, attorneys and auditors, if they agree to keep such information confidential.
Decedents: Your information can be disclosed to funeral directors, coroners and medical examiners to enable them to carry out their lawful activities.
For Product Monitoring and Recall: We may disclose information to those required by the Food and Drug Administration to monitor and repair products.
For Workers' Compensation: We may disclose information for this program.
For Research: The program may use health information for research with your consent or when a review board has approved research which poses minimal risk; your privacy is ensured or when a research project is being prepared. No public disclosure of your name will be made without your consent.
For More Information or to Report a Problem:
If you have questions, need more information or believe your privacy rights have been violated and you wish to complain, you may contact:
American Indian Health Program Manager at New York State Department of Health, Room 890 Corning Tower, Albany, New York 12237, or call (518) 474-6968 or by e-mail at email@example.com. A complaint form will be sent to you.
You may also complain to the Office for Civil Rights, Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York 10278, telephone number (212) 264-3313, fax number (212) 264-3039, TDD (212) 264-2355. You will not be retaliated against for filing a complaint or assisting an investigation.
For Programs which are covered healthcare providers, patients must sign, date and return this acknowledgment:
I acknowledge the receipt of the American Indian Health Program Notice of Privacy Practices. I also consent to the disclosure of personally identifiable information for treatment, payment and normal healthcare business operations of the covered program in regard to myself and others noted below for whom I can legally consent.
Printed Name of Enrollee/Patient
Printed Name of Others Subject to this Consent
(For example, minors)
Signature - describe legal relationship to others