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.
I. What This Is
This Notice describes the privacy
practices of Dr. Andre Spindler and Dr. Barry Bellovin
II. Our Privacy
We are required by law to maintain
the privacy of medical and health information about you ("Protected
Health Information" or "PHI")
and to provide you with this Notice of our legal duties and privacy
practices with respect to PHI. When we use or disclose PHI, we are
required to abide by the terms of this Notice (or other notice in
effect at the time of the use or disclosure).
Uses and Disclosures Without Your Written Authorization
In certain situations, which we will
describe in Section IV below, we must obtain your written
authorization in order to use and/or disclose your PHI. However, we
do not need any type of authorization from you for the following
uses and disclosures:
A. Uses and Disclosures For
Treatment, Payment and Health Care Operations. We may use and
disclose PHI in order to treat you, obtain payment for services
provided to you and conduct our "health care operations"
(e.g., internal administration, quality improvement and customer
service) as detailed below:
- Treatment. We use and
disclose PHI to provide treatment and other services to you--for
example, to diagnose and treat your injury or illness. In
addition, 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. We may
also disclose PHI to other providers involved in your treatment.
- Payment. We may use and
disclose PHI to obtain payment for services that we provide to
you--for example, disclosures to claim and obtain payment from
your health insurer, HMO, or other company that arranges or pays
the cost of some or all of your health care ("Your
or to verify that Your Payor will pay for health care.
- Health Care Operations. We
may use and disclose PHI for our health care operations, which
include internal administration and planning and various
activities that improve the quality and cost effectiveness of
the care that we deliver to you. For example, we may use PHI to
evaluate the quality and competence of our physicians, nurses
and other health care workers. We may disclose PHI to our office
manager in order to resolve any complaints you may have and
ensure that you have a pleasant visit with us.
We may also disclose PHI to your
other health care providers when such PHI is required for them to
treat you, receive payment for services they render to you, or
conduct certain health care operations, such as quality assessment
and improvement activities, reviewing the quality and competence of
health care professionals, or for health care fraud and abuse
detection or compliance.
B. Disclosure to Relatives Close
Friends and Other Caregivers. We may use or disclose PHI to a
family member, other relative, a close personal friend or any other
person identified by you when you are present for, or otherwise
available prior to, the disclosure. If you object to such uses or
disclosures, please notify the Office Manager. You should let us
know if there are specific persons who should not be given any PHI.
If you are not present, you are
incapacitated, or in an emergency circumstance, we may exercise our
professional judgment to determine whether a disclosure is in your
best interests. If we disclose information to a family member, other
relative or a close personal friend, we would disclose only
information that is directly relevant to the person's involvement
with your health care or payment related to your health care. We may
also disclose PHI in order to notify (or assist in notifying) such
persons of your location, general condition or death. Let us know of
any specific person or persons to whom PHI should not be
C. Public Health Activities.
We may disclose PHI for the following public health activities: (1)
to report health information to public health authorities for the
purpose of preventing or controlling disease, injury or disability;
(2) to report child abuse and neglect to public health authorities
or other government authorities authorized by law to receive such
reports; (3) to report information about products and services under
the jurisdiction of the U.S. Food and Drug Administration; (4) to
alert a person who may have been exposed to a communicable disease
or may otherwise be at risk of contracting or spreading a disease or
condition; and (5) to report information to your employer as
required under laws addressing work-related illnesses and injuries
or workplace medical surveillance.
D. Victims of Abuse, Neglect or
Domestic Violence. If we reasonably believe you are a victim of
abuse, neglect or domestic violence, we may disclose PHI to a
governmental authority, including a social service or protective
services agency, authorized by law to receive reports of such abuse,
neglect, or domestic violence.
E. Health Oversight Activities.
We may disclose PHI to a health oversight agency that oversees the
health care system and is charged with responsibility for ensuring
compliance with the rules of government health programs such as
Medicare or Medicaid.
F. Judicial and Administrative
Proceedings. We may disclose PHI in the course of a judicial or
administrative proceeding in response to a legal order or other
G. Law Enforcement Officials.
We may disclose PHI to the police or other law enforcement officials
as required or permitted or permitted by law or in compliance with a
court order or a grand jury or administrative subpoena.
H. Decedents. We may disclose
PHI to a coroner or medical examiner as authorized by law.
I. Organ and Tissue Procurement.
We may disclose PHI to organizations that facilitate organ, eye or
tissue procurement, banking or transplantation.
J. Research. We may use or
disclose PHI without your consent or authorization if an
Institutional Review Board/Privacy Board approves a waiver of
authorization for disclosure.
K. Health or Safety. We may
use or disclose PHI to prevent or lessen a serious and imminent
threat to a person's or the public's health or safety.
L. Specialized Government
Functions. We may use and disclose PHI to units of the
government with special functions, such as the U.S. military or the
U.S. Department of State under certain circumstances required by
M. Workers' Compensation. We
may disclose PHI as authorized by and to the extent necessary to
comply with laws relating to workers' compensation or other similar
N. As required by law. We may
use and disclose PHI when required to do so by any other law not
already referred to in the preceding categories.
IV. Use and
Disclosures Requiring Your Written Authorization
or Disclosure with Your Authorization.
For any purpose other than the ones described in Section III, we
only may use or disclose PHI when (1) you give us your authorization
on our authorization form ("Your Authorization"). For
instance, you will need to execute an authorization form before we
can send your PHI to your life insurance company, to your child's
camp or school, or to the attorney representing the other party in
litigation in which you are involved.
B. Special Authorization.
Confidential HIV-related information (for example, information
regarding whether you have ever been the subject of an HIV test,
have HIV infection, HIV-related illness or AIDS, or any information
which could indicate that you have ever been potentially exposed to
HIV) will never be used or disclosed to any person without your
specific written authorization, except to certain other persons who
need to know such information in connection with your medical care,
and, in certain limited circumstances, to public health or other
government officials (as required by law), to persons specified in a
special court order, to insurers as necessary for payment for your
care or treatment, or to certain persons with whom you have had
sexual contact or have shared needles or syringes (in accordance
with a specified process set forth in New York State law). This
special written authorization ("Your Special
Authorization") is a New York State approved form which is a
separate document from Your Authorization.
There is only one type of disclosure of confidential HIV related
information which is permitted with Your Authorization, as opposed
to Your Special Authorization: disclosures to a third party payor
for any reason other than obtaining payment for health care services
rendered to you.
A. For Further Information;
Complaints. If you desire further information about your privacy
rights, are concerned that we have violated your privacy rights or
disagree with a decision that we made about access to PHI, you may
contact our Office Manager. You may also file written complaints
with the Director, Office for Civil Rights of the U.S. Department of
Health and Human Services. Upon request, the Office Manager will
provide you with the correct address for the Director. We will not
retaliate against you if you file a complaint with us or the
B. Right to Request Additional
Restrictions. You may request restrictions on our use and
disclosure of PHI (1) for treatment, payment and health care
operations, (2) to individuals (such as a family member, other
relative, close personal friend or any other person identified by
you) involved with your care or with payment related to your care,
or (3) to notify or assist in the notification of such individuals
regarding your location and general condition. All requests for such
restrictions must be made in writing. While we will consider all
requests for additional restrictions carefully, we are not required
to agree to a requested restriction. If you wish to request
additional restrictions, please obtain a request form from our
Office Manager and submit the completed form to the Office Manager.
We will send you a written response.
C. Right to Receive Confidential
Communications. You may request, and we will accommodate, any
reasonable written request for you to receive PHI by alternative
means of communication or at alternative locations.
D. Right to Inspect and Copy Your
Health Information. You may request access to your medical
record file and billing records maintained by us in order to inspect
and request copies of the records. All requests for access must be
made in writing. Under limited circumstances, we may deny you access
to your records. If you desire access to your records, please obtain
a record request form from the Office Manager and submit the
completed form to the Office Manager. If you request copies, we may
charge 75 cents for each page.
You should take note that, if you are a parent or legal guardian of
a minor, certain portions of the minor's medical record will not be
accessible to you (for example, records relating to venereal
disease, abortion, or care and treatment to which the minor is
permitted to consent himself/herself (without your consent) such as
HIV testing, sexually transmitted disease diagnosis and treatment,
chemical dependence treatment, prenatal care, care received by a
married minor, and contraception and/or family planning services).
E. Right to Revoke Your
Authorization. You may revoke Your Authorization, Your Special
Authorization, or Your Marketing Authorization, except to the extent
that we have taken action in reliance upon it, by delivering a
written revocation statement to the Office Manager identified below.
[A form of Written Revocation is available upon request from the
F. Right to Amend Your Records.
You have the right to request that we amend PHI maintained in your
medical record file or billing records. If you desire to amend your
records, please obtain an amendment request form from the Office
Manager and submit the completed form to the Office Manager. All
requests for amendments must be in writing. We will comply with your
request unless we believe that the information that would be amended
is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting
of Disclosures. Upon written request, you may obtain an
accounting of certain disclosures of PHI made by us during any
period of time prior to the date of your request provided such
period does not exceed six years and does not apply to disclosures
that occurred prior to April 14, 2003.
H. Right to Receive Paper Copy of
this Notice. Upon written request, you may obtain a paper copy
of this Notice, even if you agreed to receive such notice
Date and Duration of This Notice
A. Effective Date. This Notice
is effective on April 14, 2003.
B. Right to Change Terms of this
Notice. We may change the terms of this Notice at any time. If
we change this Notice, we may make the new notice terms effective
for all PHI that we maintain, including any information created or
received prior to issuing the new notice. If we change this Notice,
we will post the revised notice in waiting areas of the Practice
[and on our Internet site at www.TheCardiologist.md]. You may also
obtain any revised notice by contacting the Office Manager.
You may contact the Office Manager at
Andre B. Spindler, MD
Barry J. Bellovin, MD
23-35 Bell Boulevard
Telephone Number: 718-229-2121
Fax Number: 718-229-3502