As you permitted upon admission/registration, the following is a description of the types of uses and disclosures of medical information about you that the Hospital, or contractors using or disclosing medical information on behalf of the Hospital, may make:

Treatment. We may use medical information about you in order to provide you with medical treatment. For example, a doctor treating you for a hip fracture may need to know if you have diabetes because diabetes may affect the healing process. We may disclose medical information about you to Hospital personnel or another health care provider involved in treating you. For example, a doctor may need to tell the dietitian if you have diabetes so that the Hospital can arrange for appropriate meals. We also may disclose medical information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital.
Payment. We may use and disclose medical information about you so that the Hospital can get paid for the services it gives you. For example, we may need to give your health plan information about rehabilitation you received at the Hospital so it will pay us or reimburse you for services rendered. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
Health Care Operations. We may use and disclose medical information about you for general administrative and business functions necessary for operation of the Hospital. For example, we may use medical information about you to assess the quality of care we are giving to our patients, to review the competence of health care professionals working at the Hospital, to train medical students, to make sure we are complying with legal rules and regulations or to conduct business planning or management or other general administrative activities.

In addition to the uses and disclosures listed above:
Individuals Involved in Your Care. With your permission, we may disclose to a family member, other relative or close personal friend, medical information directly relevant to that person’s involvement with your care or payment related to your health care. We may also notify your family or other person involved with your health care that you are in the Hospital.
Hospital Directory. If you do not object, we may include certain limited information about you in the Hospital directory while you are a patient at the Hospital. This information may include your name, location in the Hospital, a description of your condition in general terms that does not communicate specific medical information about you and your religious affiliation. The directory information, except for your religious affiliation, may be disclosed to people who ask for you by name. Your religious affiliation may be given to members of the clergy, such as priests or rabbis, even if they do not ask for you by name. This is so your family, friends and clergy can visit you in the Hospital and generally know how you are doing.
Appointment Reminders. We may use and disclose medical information about you to 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.
Reviews Preparatory to Research. We may use and disclose medical information about you without your consent if necessary for reviews preparatory to research, but none of your medical information would be removed from the Hospital in the course of such reviews. For example, in order to prepare for research on rehabilitation of female hip fracture patients over the age of 75 with osteoporosis, it would be necessary to review Hospital medical records to determine which patients might be appropriate subjects for such research.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients with a particular condition who received one type of rehabilitation to those who received another. Before we use or disclose medical information about you for research, the project would have to be approved through a process that the Hospital uses for the protection of human research subjects. We will ask for your specific permission (with exception in those instances allowed by law) if the researcher will be using or disclosing medical information about you for research and will have access to your name, address or other information that could be used to identify who you are.
Fundraising Activities. We may contact you to raise funds for the Hospital. To do so, we would disclose some information about you to the Hospital’s Foundation, so that the Foundation may contact you to raise money for the Hospital. We would only release contact information, such as your name, address and phone number and the dates you received treatment or services at the Hospital. If you do not want the Hospital to contact you for fundraising efforts, you must notify in writing to the Director of Development, Development Department, Helen Hayes Hospital. Route 9W, West Haverstraw, New York 10993, and phone number 845-786-4365 for further information on filing such requests.
Workers’ Compensation. We may release medical information about you for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.
Coroners, Medical Examiners and Funeral Directors. We may disclose medical information to a coroner or medical examiner for the purpose of identifying a deceased person or determining a cause of death, or to funeral directors as necessary for them to carry out their duties.
Organ and Tissue Donation. If you are an organ donor, the Hospital may use or disclose medical information about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaver organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
Government Authorities. We may use and disclose medical information about you when necessary to report evidence of a crime or to prevent a serious threat to your health or safety or the health or safety of the public or another person, including the reporting of cases of suspected child abuse or maltreatment.
As Otherwise Required By Law. We will disclose medical information about you when required to do so by federal, State or local law. For example, we are required by law to disclose certain information about patients to public health authorities and health oversight agencies.
As Otherwise Permitted or Required by Federal Standards. We may disclose medical information about you as permitted or required by federal Standards for Privacy of Individually Identifiable Health Information issued by the United States Department of Health and Human Services.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Director of Medical Records, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4116 for further information.
In your request, you must tell us:

• what information you want to limit;
• whether you want to limit our use, disclosure or both; and
• to whom you want the limits to apply.

Right to Receive Confidential Communications. You have the right to request that we communicate with you about medical matters by alternative means or at alternative locations. For example, you can ask that we only contact you at work.

To request confidential communications, you must make your request in writing to the Director of Patient Relations, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4210 for further information on such requests. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used by the Hospital to make decisions about you.

To request access to your records, you must submit your request in writing to the Director of Medical Records, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4116 for further information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed as required by law. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.

To request an amendment, your request must be made in writing and submitted to the Director of Medical Records, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4116 for further information. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting” of disclosures. This is a list of disclosures we made of medical information about you, but the list does not include disclosures for treatment, payment, or health care operations, those specifically authorized by you or certain disclosures for law enforcement purposes.

To request this accounting of disclosures, you must submit your request in writing to the Director of Medical Records, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4116 for further information. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Hospital. The notice will contain the effective date. Each time you are admitted to the Hospital for treatment or health care services as an inpatient we will offer you a copy of the current notice in effect. If you are registered as an outpatient to the hospital for treatment and health care services, we will offer you a copy of the current notice in effect at the time of your first visit.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Office of Civil Rights, United States Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278 and phone number 212-264-3313, fax number 212-264-3039, TDD 212-264-2355. To file a complaint with the Hospital, contact the Director of Patient Relations at Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4210 for further information. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint

Questions

If you have any questions about this notice, please contact the Director of Patient Relations, Helen Hayes Hospital, Route 9W, West Haverstraw, New York, 10993 and phone number 845-786-4210 for further information.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Helen Hayes Hospital Notice of Privacy Practices. Effective Date: April 14, 2003