EASTERN LONG ISLAND HOSPITAL
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.

I. Who Will Follow This Notice:

Eastern Long Island Hospital provides health care to patients jointly with physicians and other health care professionals and organizations. The privacy practice described in this notice will be followed by any health care professional who treats you at any of our locations and all employees, medical staff, students, volunteers or business associates of our hospital.

II. Our Commitment to Your Privacy:

We are dedicated to maintaining the privacy of your medical information. In conducting our services, we will create records regarding you and the treatment and services we provide to you (including any records relating to psychiatric treatment, drug and alcohol treatment or abuse or HIV status, if any). These records are our property, however we are required by law to maintain the privacy of medical and health information about you (“Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health Information, we are required to abide by the terms of this Notice (or other Notice in effect at the time of the use or disclosure).

III. Uses and Disclosures With Your Authorization:

A. Use or Disclosure with Your Authorization. We may use or disclose Protected Health Information only when (1) you give us your written authorization on a form that complies with the Health Insurance Portability and Accountability Act (“Your Authorization”) or (2) there is an exception described in Section IV below. Further, except to the extent that we have taken action in reliance upon it, you may revoke Your Authorization by delivering a written revocation statement to the Privacy Office identified below.

B. Genetic Information. Except in certain cases (such as a paternity test for a court proceeding, anonymous research, or pursuant to a court order), we will obtain Your Authorization prior to obtaining or retaining your genetic information (for example, your DNA sample). We may use or disclose your genetic information for any reason only when Your Authorization expressly refers to your genetic information or when disclosure is permitted under New York State law (including, for example, when disclosure is necessary for the purposes of a criminal investigation, to determine paternity, identifying your body or as otherwise authorized by a court order).

C. AIDS or HIV Related Information. If Protected Health Information contains AIDS or HIV related information, that information is confidential and shall not be disclosed without your written authorization, except as follows. Such information may be released without Your Authorization to medical personnel directly involved in your medical treatment. If you are deemed to lack decision-making capacity, we may release such information (only if necessary and unless you request otherwise) to the person responsible for making health care decisions on your behalf (spouse, primary caretaking partner, an appropriate family member, etc.). Under certain circumstances, such information may also be released without your authorization for scientific research, certain audit and management functions, and as may otherwise be allowed or required by law or court order.

D. Alcohol or Drug Abuse Programs. If Protected Health Information contains information related to treatment provided in one of our alcohol or drug abuse programs, that information is confidential and shall not be disclosed without Your Authorization, expressly releasing alcohol or drug abuse related information except as follows. Under certain circumstances, such information may be released without Your Authorization: (1) for internal communications; (2) if there is no patient-identifying information; (3) for medical emergencies; (4) in order to report and/or investigate crimes committed at the Program or against its personnel; and (5) as may otherwise be allowed or required by law or court order.

E. Psychotherapy Notes. Protected Health Information containing psychotherapy notes will not be released without Your Authorization, expressly releasing psychotherapy related information except as follows. Under certain circumstances, such information may be released without Your Authorization: (1) To carry out treatment, payment or health care operations; and (2) a use or disclosure is required by law, regarding disclosures to individuals as requested by a health care provider, regarding disclosures to health oversight agencies with respect to the oversight of the originator of the psychotherapy notes, regarding disclosures to coroners and medical examiners, or permitted by medical examiners, or regarding uses and disclosures necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.

F. Marketing Communications. We will obtain Your Authorization for the use or disclosure of your Protected Health Information for marketing purposes. However, this does not apply to communications that are made: (1) face-to-face by our staff to you; (2) to describe a health-related product or service that is offered by us; (3) for your treatment; or (4) for your care management or to direct or recommend alternative treatments or health care providers.

IV. Uses and Disclosures Without Your Authorization:

A. Use and/or Disclosure For Treatment, Payment and Health Care Operations. Except as noted in III B, C, D, E and F above, we may use and/or disclose Protected Health Information without your authorization, for treatment provided to you, obtaining payment for services provided to you and for health care operations (e.g., internal administration, quality improvement, customer service, etc.) as detailed below:

• Treatment. We use and disclose your Protected Health Information to provide treatment and other services to you - for example, to diagnose and treat your injury or illness. We may also disclose your Protected Health Information for the treatment activities of another health care provider. 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.

• Payment. We may use and disclose your Protected Health Information 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 Payor”) to verify that Your Payor will pay for the services provided. We may also disclose your Protected Health Information to another health care provider for the payment activities of that health care provider.

• Health Care Operations: We may use and disclose your Protected Health Information 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 your Protected Health Information to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose your Protected Health Information to our patient representatives in order to resolve any complaints you may have and ensure that you have a comfortable visit with us. We may disclose your Protected Health Information to contractors, agents and other business associates in order to assist with carrying out our operations. Under certain circumstances, we may disclose your Protected Health Information to another health care provider for the health care operations of that health care provider if they either have treated or examined you and your Protected Health Information pertains to that treatment or examination. Lastly, we may disclose information to doctors, nurses, technicians, students and others for review or learning purposes.

B. Use or Disclosure for Directory of Individuals in ELIH. Unless you disagree or object, we may include your name, location in ELIH, general health condition and religious affiliation in a patient directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy (provided, however, that religious affiliation will only be disclosed to members of the clergy).

C. Disclosure to Relatives and Close Friends. We may use or disclose your Protected Health Information 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 for the purpose of involvement in your healthcare if we: (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests.

D. Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of ELIH. In connection with any fundraising, we may disclose to our related foundation/fundraising staff demographic information about you (e.g., your name, address and phone number) and dates of health care that we provided to you.

E. Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes as required by law: (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 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.

F. Health Oversight Activities. We may disclose your Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.

G. Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

H. Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

I. Decedents. We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.

J. Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

K. Research. We may use or disclose your Protected Health Information without your consent or authorization if our Institutional Review Board approves a waiver of authorization for disclosure.

L. Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

M. Specialized Government Functions. We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

N. Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

V. Your Individual Rights:

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 your Protected Health Information, you may contact our Privacy Official. If we can not satisfy your complaint, you may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Official will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with the Director or us.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information: (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. 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, and submit the completed form to, our Privacy Official. 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 your Protected Health Information 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. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from, and submit the completed form to the Medical Records Department at 201 Manor Place, Greenport, NY 11944. If you request copies, we will charge you .75cents 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 pregnancy, abortion, sexually transmitted disease, substance use and abuse, contraception and/or family planning services).

E. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from, and submit the completed form to, our Privacy Official. 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. You may appeal our decision to deny the requested amendment by contacting the Privacy Official in writing.

F. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of Protected Health Information 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. If you request an accounting more than once during a twelve (12) month period, we will charge you $1.00 (one dollar) per page for the accounting statement.

G. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically you can also access this notice on our website at www.elih.org

VI. Effective 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 Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around ELIH and on our Internet site at www.elih.org. You also may obtain any new notice by contacting the Privacy Official.

VII. Privacy Official:

Pat Kiernan, Vice President of Development
Eastern Long Island Hospital
201 Manor Place
Greenport, NY 11944
(631) 477-5434