Notice of Privacy Practices

We are committed to protecting your privacy. This notice describes how clinical information about you may be used and disclosed and how you (the individual who is receiving services) can get access to this information.

HOW WE MAY USE YOUR CLINICAL HEALTH INFORMATION

 

1. We will not disclose clinical information about you without your consent or written authorization, except for:

“treatment” we may share clinical information about you inside our agency or with another agency, to plan for and provide services for you.  For example, we may disclose information about you to assist with a job placement or training program.

 

“payment” we may use clinical information about you, or share it with others, so that we obtain payment for your services.

 

“operations” we may use clinical information about you, or share it with others, in order to conduct our normal business operations.  For example, we may use clinical information about you to evaluate the performance of our staff in providing services to you

  • to a personal representative authorized to make health care decisions on your behalf;

  • to government agencies or private insurance companies to obtain payment

  • to comply with a court order;

  • to avert a serious and imminent threat to the health or safety of you or another person;

  • to locate a missing person or conduct a criminal investigation

  • to emergency services as permitted under Federal and State confidentiality laws;

  • to an attorney representing you in an involuntary hospitalization or medication proceeding.  (We will not disclose clinical information about you to an attorney for any other reason without your authorization, unless we are ordered to do so by a court).

  • to authorized officials for monitoring the quality of care provided by the agency

  • to qualified researchers when such research poses minimal risk to your privacy;

  • to coroners and medical examiners to determine cause of death;

  • If you are an inmate, to your correctional facility in order to provide you with health care, or to protect your health or safety or any other persons at the correctional facility.

  • Funeral Directors as necessary to carry out their duties.

  • Organ and Tissue Donation. Your organs would not be used without written consent by a legally authorized person.

  • If we have removed any information that might reveal who you are.

  • Emergencies Or Public Need. For example, we may share your information to investigate and control the spread of diseases.

  • As Required By Law if a court orders us to do so in a lawsuit or judicial proceeding. 

  • Victims 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. 

  • National Security and Intelligence Activities or Protective Services who are conducting services to the President or other important officials.

2. If you do not object, we may disclose information about you in the following situations:

Disclosure to friends and family involved In your care.  Please let us know if you have any objections to sharing clinical information about you to your friends and family involved in your care. To object to the sharing of clinical information, please write to QSAC’s Privacy Officer: Timothy Burke, QSAC, 25-09 Broadway, Astoria, NY 11106.

3. Special Situations

  • Fundraising. We may use demographic information about you (such as your age, gender, where you live or work, and the dates that you received services) in order to contact you to raise money to help us operate.  We may also share this information with a charitable foundation that will contact you to raise money on our behalf.  If you do not want to be contacted for these fundraising efforts, please write to Timothy Burke, QSAC, 25-09 Broadway, Astoria, NY, 11106.

  • Research. In most cases, we will ask for your written authorization before using clinical information about you or sharing it with others in order to conduct research.  However, under some circumstances, we may use and disclose your clinical 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.

  • If we do not allow researchers to use your name or identity publicly.

  • 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 clinical 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.

WHAT INFORMATION IS PROTECTED

Some examples of protected clinical information are:

  • the fact that you are a participant at, or receiving services from, our agency;

  • information about your condition;

  • information about health care products or services you have received (such as a medication or treatment); or

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

when combined with:

  • 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, your phone number, or your Medicaid number); and 

  • other types of information that may identify who you are.

Incidental Disclosures.  We will take reasonable steps to safeguard the privacy of your health information, but certain incidental disclosures of your information may occur during permissible use.  For example, during the course of a treatment session, other consumers in the treatment area may see, or overhear discussion of, your health information.

1. Right to Inspect and Copy Records

You have the right to inspect and obtain a copy of any of your clinical 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 copy of your clinical information, please submit your request in writing to QSAC’s Privacy Officer, Timothy Burke, at QSAC, 25-09 Broadway, Astoria, NY, 11106.  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 30 days if the information is located in our facility, and within 60 days if it is located off-site at another facility.  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 circumstances, we may deny your request to inspect or obtain a copy of your information.  If we do, we will provide you with a summary of the information instead.  We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights.  The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services.  If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.

2. Right to Request Amendment of Records 

You have the right to request that we amend your clinical information if you believe that the information is incorrect or incomplete.  To request an amendment, please write to QSAC’s Privacy Officer, Timothy Burke at QSAC, 25-09 Broadway, Astoria, NY 11106.  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.

 

If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so.  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 a right to request an “accounting of disclosures” which is a list that contains certain information about how we have shared your information with others for non-routine disclosures.  An accounting list will not include:

 

  • Disclosures we made to you;

  • Disclosures we made pursuant to your authorization;

  • Disclosures we made for treatment, payment or health care operations;

  • Disclosures made in the facility directory;

  • Disclosures made to your friends and family involved in your care or payment for your care;

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

  • Disclosures that were incidental to permissible uses and disclosures of your clinical information;

  • Disclosures for purposes of research, public health or our normal business operations of limited portions of your health information that do not directly identify you;

  • Disclosures about inmates to correctional institutions or law enforcement officers; or

  • Disclosures made before April 14, 2003.

 

To request this accounting list, please write to QSAC’s Privacy Officer, Timothy Burke at QSAC, 25-09 Broadway, Astoria, NY 11106.  Your request must state a time period within the past six years for the disclosures you want us to include. You have a right to receive one accounting list within every 12-month period for free.  However, we may charge you for the cost of providing any additional accounting list in that same 12-month period.  Ordinarily we will respond to your request for an accounting 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.  In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.

4. Right to Request Additional Privacy Protections

 

You have the right to request restrictions of the way we use your clinical information about you or share it with others.  You may request that we limit how we disclose information about you to family or friends involved in your care.  For example, you could request that we not disclose information about a surgery you had.  To request restrictions, please write to QSAC’s Privacy Officer, Timothy Burke, at QSAC, 25-09 Broadway, Astoria, NY 11106.  Your request should include: (1) what information you want to limit; (2) whether you want to limit how we use the information or how we share it with others or both; and (3) to whom you want the limits to apply. 

 

We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law.  However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law.  Once we have agreed to a restriction, you have the right to revoke the restriction at any time.  Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so.

5. Right to Request Confidential Communications

You have the right to request that we contact you in a way that is more confidential for you, such as at home instead of at work.  You can request that we communicate with you about matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations.  For example, you may ask that we contact you by fax instead of by mail, or at work instead of at home.  To request more confidential communications, please write to QSAC’s Privacy Officer, Timothy Burke, at QSAC, 25-09 Broadway, Astoria, NY 11106We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.  Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location.

 

How Someone May Act On Your Behalf.  You have the right to name a personal representative who may act on your behalf to control the privacy of your clinical information.  Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.

 

How To Learn About Special Protections For HIV, Alcohol And Substance Abuse, Mental Hygiene and Genetic Information.  Special privacy protections apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information.  Some parts of this general Notice of Privacy Practices may not apply to these types of information. 

 

Current notices will be accessible in our reception areas, on our website at www.QSAC.com or by calling our office at (718) 728-8476. For questions, please contact QSAC’s Privacy Officer, Timothy Burke at (718) 728-8476, ext. 1236.

 

How To File A Complaint.  If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.  To file a complaint with us, please contact QSAC’s Privacy Officer at (718) 728-8476, ext. 1236 or write to QSAC, 25-09 Broadway, Astoria, NY, 11106.  No one will retaliate or take action against you for filing a complaint.

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