Notice of Privacy Practices

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Effective Date: September 23, 2013

CMH Services, Inc., d/b/a Cortland Medical Supply

160 Homer Avenue

Cortland, New York 13045

NOTICE OF 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.

If you have any questions about this Notice, please contact the

Privacy Officer at 607-756-3687

A. PURPOSE OF THIS NOTICE OF PRIVACY PRACTICES

WHO WILL FOLLOW THIS NOTICE

This Notice describes the privacy practices of CMH Services, Inc., known as Cortland Medical Supply (“CMH”). CMH will follow this Notice, as will our:

· Health care professionals who are authorized to enter information into your medical record;

· Employees, personnel or representatives having access to your medical information; and

· Affiliates, including independent contractors, who have access to your medical information in order to provide the services we have asked them to do. Notwithstanding the applicability of this Notice to affiliates, CMH does not assume any liability for any negligence or professional malpractice on the part of or committed by these affiliates.

These individuals and CMH may share your health information with each other as may be necessary to provide you treatment, for payment of your treatment, or to support CMH’s healthcare operations to the extent authorized by law.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We create a record of the care and services CMH provides to you. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by CMH and its affiliates. Your personal doctor and other health care providers may have different policies or notices regarding use and disclosure of your medical information created by them.

This Notice tells you about the ways in which we may use and disclose medical information about you. This Notice also describes your rights and our obligations regarding the use and disclosure of medical information.

We are required by law to 1) protect the privacy of health information that may reveal your identity, 2) abide by the terms and conditions of the Notice of Privacy Practices currently in effect, 3) provide you with a copy of this Notice which describes the health information privacy practices of CMH, its health care providers and staff that perform our payment activities and business operations; and 4) notify you of a breach of unsecured protected health information.

A copy of our current Notice of Privacy Practices will always be posted in our office. You will be provided with a copy of this Notice when we first provide you with services.

WHAT HEALTH INFORMATION IS PROTECTED

We are committed to protecting the privacy of the information that we gather about you while providing health-related services. Some examples of protected health information are:

· Information about your health condition (such as a disease you may have);

· Information about healthcare services you have received or may receive in the future (such as respiratory therapy);

· Information about your health care benefits under an insurance plan (such as whether a prescription is covered);

· Geographic information (such as where you live or work);

· Demographic information (such as your race, gender, ethnicity, or marital status);

· Unique numbers that may identify you (such as your social security number, phone number, or driver's license number); and

· Other types of information that may identify who you are.

B. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION

1. TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

CMH and its health care providers and staff may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run CMH's normal health care operations, without your permission. Your health information may also be shared with affiliated hospital/nursing facilities and health care providers so that they may jointly perform certain treatment, payment activities and health care operations. Below are some examples of how your information may be used without your authorization for treatment, payment and health care operations.

Treatment. We may share your health information with doctors, nurses, technicians, students or other personnel who are involved in your care and they may in turn use that health information to diagnose or treat you. Our staff may need to share your information with another provider as part of a referral or consultation. We may also share medical information about you with non-CMH providers, agencies or facilities in order to provide or coordinate the different services or medical equipment that you may need. We also may disclose medical information about you to people outside of CMH who may be involved in your continuing medical care, such as health care providers, transport companies, community agencies and family members.

Payment. We may use your health information or share it with others so we may obtain payment for your health care services. For example, we may share information about you with your health insurance company in order to obtain reimbursement after we have provided items or services to you. In some cases, we may share information about you with your health insurance company to determine whether it will cover your medical item or service. We might also need to inform your health insurance company about your health condition in order to obtain pre-approval for a particular type of medical equipment.

Health Care Operations. We may use your health information or share it with others in order to conduct our normal business operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide to you.

2. OTHER USES AND DISCLOSURES

There are other special situations when we may use and disclose your health information without your authorization. These uses and disclosures are listed below.

Appointment Reminders, Treatment Alternatives, Benefits, And Services. We may use your health information when we contact you with a reminder that you have an appointment for services. We may also use your health information in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.

Face-to-Face Communications and Promotional Gifts of Nominal Value. We may use your health information to engage in face-to-face communications with you regarding our products and services or to provide you with promotional gifts of nominal value.

Friends And Family Involved In Your Care. Unless you object, or as otherwise instructed by you, or as authorized by law, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative or another person responsible for your care in the unfortunate event of your death. In some cases, we may need to share information with a disaster relief organization so that your family or friends can be notified about your condition.

News Gathering Activities. We may contact you or a family member when a news reporter has requested an interview with you. News reporters often seek interviews with patients injured in accidents or experiencing particular medical conditions or procedures. For example, a reporter working on a story about a new cancer therapy may ask whether any of the patients undergoing that therapy might be willing to be interviewed. In such cases, a member of our staff would contact you to discuss whether or not you want to participate in the story.

As Required By Law. We may use or disclose your health information if we are required by law to do so. We also will notify you of these uses and disclosures if the law requires notice.

Public Health Activities. We may disclose your health information to public health authorities that are authorized by law to receive and collect health information for purposes of preventing or controlling disease, injury or disability; to report births, deaths, suspected abuse or neglect, reactions to medications, food or defects or problems with products; to facilitate product recalls; or to notify a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

Victims Of Abuse, Neglect Or Domestic Violence. As authorized or required by law, we may release your health information to a public health or government authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we may report your information to government officials if we reasonably believe that you have been a victim of abuse, neglect or domestic violence. We will make reasonable efforts to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.

Health Oversight Activities. As authorized or required by law, we may release your health information to government agencies and accreditation agencies authorized to conduct audits, investigations, licensure, certification or accreditation surveys, and inspections of our facility. These government and accreditation agencies monitor the operation of the health care system, government benefit programs such as, Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Medical Product Monitoring, Repair and Recall. We may disclose your health information to a person or company that is required by the Food and Drug Administration to: (1) report or track product defects or problems: (2) repair, replace, or recall defective or dangerous products; or (3) monitor the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. In connection with lawsuits or other legal proceedings, we may, as authorized or required by law, disclose your health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other unlawful process.

Law Enforcement. We may disclose your health information to law enforcement officials if asked to do so by law enforcement officer, and as authorized or required by law, for the following reasons:

· To comply with a court order or laws that we are required to follow;

· To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person.

· If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your consent because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interest;

· If we suspect that your death resulted from criminal conduct;

· If necessary to report a crime that occurred on our property; or

· If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).

To Avert A Serious Threat To Health Or Safety. As authorized or required by law, we may use your health information or share it with others when necessary to prevent a serious threat to your health or safety, or the health or safety of another person or the public. In such cases, we will only share your information with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine that you escaped from lawful custody (such as a prison or mental health institution).

National Security And Intelligence Activities or Protective Services. As authorized or required by law, we may disclose your health information to authorized federal officials who are conducting national security and intelligence or counter intelligence activities or providing protective services to the President or other important officials.

Military And Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission as authorized or required by law. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates And Correctional Institutions. As authorized or required by law, if you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or other persons involved in supervising or transporting inmates.

Workers’ Compensation. As authorized or required by law, we may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries when your health condition arises out of a work-related illness or injury.

Coroners, Medical Examiners And Funeral Directors. We may disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.

Organ And Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your authorization if we obtain approval through a special process to ensure that research without your authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your health information without your authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.

C. USES AND DISCLOSURES THAT WILL ONLY BE MADE WITH YOUR AUTHORIZATION.

We will only make the following uses and disclosures with your written authorization:

· Most uses and disclosures of psychotherapy notes;

· Uses and disclosures of health information for marketing purposes;

· Disclosures that would be considered a sale of health information; and

· Other uses and disclosures not otherwise described in this Notice or covered by the laws that apply to us. In those instances, we will provide you with an authorization form to sign.

If you provide us permission to use or disclose your health information, 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 authorization, except to the extent we have already relied upon it. You understand that we are unable to take back any disclosures we have already made with your permission. Depending upon the nature of your health information, we may be required by law to comply with additional requirements prior to using or disclosing your health information. For example, use and disclosure of HIV-related, genetic and mental health information may need your specific permission.

D. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters.

Please contact the Privacy Officer/Director of Health Information Management at 607-756-3687 if you have questions, complaints, or require additional information to exercise any of your privacy rights. Written requests may be sent to the following address:

Privacy Officer/Director of Health Information Management

Cortland Regional Medical Center

134 Homer Avenue, P.O. Box 2010

Cortland, New York 13045-0960

1. RIGHT TO INSPECT AND COPY RECORDS

With certain exceptions, you have the right to inspect and obtain a paper or electronic copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes medical and billing records. To inspect or obtain a paper of electronic copy of your medical record, please submit your request in writing to the address listed above. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. The standard fee is $0.75 per page and must generally be paid before or at the time we give the copies to you.

We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 10 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.

Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If you are denied access to your medical information, you may request that the denial be reviewed.

2. RIGHT TO REQUEST AN AMENDMENT OF RECORDS

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. To request an amendment, please submit your request in writing to the address listed above. Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

We may deny your request if the information sought to be amended: (a) was not created by us; (b) is not part of the information kept by or for us; (c) is not part of the information which you are permitted to inspect and copy; or (d) is accurate and complete in the record. If we deny all or part of your request, we will provide a written notice that explains our reasons for doing so. We may also deny your request for an amendment if it is not in writing or does not include a reason. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

3. RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an “accounting of disclosures” which is a list with information about how we have shared your information with others. The accounting, however, will not include:

· Disclosures we made to you;

· Disclosure made pursuant to a written authorization;

· Disclosures we made in order to provide you with treatment, obtain payment for that treatment, or conduct our normal health care operations;

· Disclosures made to your friends and family involved in your care;

· Disclosures made to federal officials for national security and intelligence activities; or

· Disclosures about inmates to correctional institutions or law enforcement officers.

To request this accounting, please submit your request in writing to the address listed above. Your request must state a time period covering the accounting of disclosures, not to exceed the six years prior to your request. You should indicate in what form you want the list (for example, on paper or electronically). For example, you may request a list of the disclosures that we made between January 1, 2012 and January 1, 2013. You have a right to one accounting within every 12 month period for free. However, we may charge you for the cost of providing any additional accountings in that same 12 month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. Ordinarily we will respond to your request for a list within 60 days. If we need additional time to prepare the accounting list you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting list.

4. 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. You also have the right to request that we limit how we disclose medical information about you to family or friends involved in your care or the payment of your care. For example, you could ask that we not use or disclose information about a medical condition you may have.

Generally, we are not required to agree to your request to restrict how we use and disclose your medical information. Except however, if you request we restrict the disclosure of your health information to a health plan (your health insurer) related to services or items we provide to you and you pay us for such services or items out-of-pocket in full, we must agree to your request, unless we are required by law to disclose the information. Please note: This restriction will apply only when requested and services are paid in full. Future services without a restriction request and for which no out-of-pocket payment is received will be billed per provider and health plan policy, which may include current provider notes that reference prior treatments or services previously restricted.

If we do agree to a restriction, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment. If we intend to terminate our agreement to your requested restriction we will notify you.

To request restrictions, please submit your request in writing to the address listed above. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

5. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS

You have the right to request that we communicate with you about your medical matters in a more confidential way. For example, you may ask that we contact you at work instead of at home. To request more confidential communications, please submit your request in writing to the address listed above. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through the alternative method or location.

E. HOW TO OBTAIN A COPY OF THIS NOTICE

You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time even if you agreed to receive this Notice electronically. To do so, please contact the Privacy Officer, at 607-756-3687. You may also obtain a copy of this Notice from our website at http://www.cmhhomehealthcare.com or by requesting a copy the next time you receive services.

F. HOW TO OBTAIN A COPY OF REVISED NOTICES

We may change our privacy practices and this Notice from time to time. If we do, we will revise this Notice so you will have an accurate summary of our practices. We reserve the right to make the revised Notice effective for medical information we already have about you as well as any information we receive in the future. The revised Notice will apply to all of your health information, and we will be required by law to abide by its terms. We will post any revised Notice in our office. You will also be able to obtain your own copy of the revised Notice by accessing our website at http://www.cmhhomehealthcare.com or calling the Privacy Officer at 607-756-3687 or asking for one the time you receive services. The effective date of the Notice will always be located on the first and last page.

G. HOW TO FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a complaint with CMH by contacting the Privacy Officer at 607-756-3687 or the Secretary of the US Department of Health and Human Services. To better serve you, we ask that you put your complaint to us in writing and send it to:

Privacy Officer

Cortland Regional Medical Center

134 Homer Avenue, P.O. Box 2010

Cortland, New York 13045-0960

No one will retaliate or take action against you for filing a complaint.

Effective Date: September 23, 2013