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 Hospital's Privacy Officer Monica Broderick, 914-763-8151, ext. 2349.

WHO WILL FOLLOW THIS NOTICE:

This Notice describes Four Winds Hospital's privacy practices and the practices of the following:

• Any health care professional authorized to enter information into your Four Winds Hospital medical record
• All departments and units of the Hospital
• All employees, staff and other Hospital personnel
  

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive while at the Hospital. We need this medical record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the medical records of your care generated by the Hospital.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. Both federal and state privacy laws apply to the ways in which we may disclose information. We are required by law to:

• Make sure that medical information that identifies you is kept private
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you
• Follow the terms of the Hospital's Privacy Practices Notice that is currently in effect
  

For certain types of disclosures of information in your medical record at a psychiatric hospital, New York State law may be more stringent than the federal law. For example the New York Mental Hygiene Law generally does not permit the disclosure of a clinical record except under circumstances specifically set forth in the law. The Hospital will follow New York law when it is more restrictive.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, social workers, counselors, medical students, or other Hospital personnel who are involved in taking care of you at the Hospital. For example, the doctor may need to share information with the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and EKG's. We also may disclose medical information about you, with your written authorization, to people outside the Hospital who may be involved in your medical care after you leave the hospital, such as outpatient treatment providers, family members, clergy or others.

Payment: We may use and disclose medical information about you so that the treatment and services you receive at the Hospital may be billed to and payment may be collected from you and/ or an insurance company or a third party. For example, we may need to give your health plan information about care you receive at the Hospital so your health plan will pay us or reimburse you for this care. 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 Hospital operations. These uses and disclosures are necessary to run the Hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may combine medical information about many Hospital patients to decide what additional services the Hospital should offer, what services are not needed, and whether changes should be made in the delivery of care. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We will remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning your identity.

Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: We will only release medical information about you to a friend or family member when you have given us written authorization.

As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.

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 all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through the research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project for certain purposes, such as to help the researchers look for patients with specific medical needs, so long as the medical information the researchers review does not leave the Hospital. We will almost always ask for your specific permission if the researcher will be involved in your care at the Hospital. We will ask for your permission if the researcher needs your participation in the research in some way, such as asking you to fill out a questionnaire or asking you to provide information to the researcher after your discharge from the Hospital.

To Avert a Serious Threat to Health or Safety or in the Event of a Disaster: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat. In cases of a local disaster, we may tell your next of kin whether you are safe, we may cooperate with other hospitals and relief agencies, and we may release general information to the public to help reduce public anxiety.

Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities so long as such disclosures are consistent with New York State law and policy.

Worker's Compensation: We may release medical information about you for worker's compensation or similar programs, but only with your written authorization. These programs provide benefits for work-related injuries or illness.

Law Enforcement: We may release medical information, which may be required by law to be limited to identifying information, in connection with law enforcement activities under the following circumstances:

• To locate missing persons
• In connection with a criminal investigation
• About a death we believe may be the result of criminal conduct
• About criminal conduct at the Hospital
• When a psychiatrist has determined that a patient or client presents a serious or imminent danger to another individual
  

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, there may be times when the Hospital will be required to disclose certain information about you in response to a court order. However, the Hospital will comply with the requirements of the New York Mental Hygiene Law which provides that a clinical record of a patient in a psychiatric hospital can be released without the patient's consent pursuant to a court order only after a finding that the interests of justice significantly outweigh the need for confidentiality. You may always provide us with a written authorization to release information to your lawyer, the court, or to a lawyer representing another party in the lawsuit or dispute.

Public Health Risks: We may disclose medical information about you for public health activities. The activities generally include the following:

• To prevent or control disease, injury or disability
• To report births and deaths
• To report child abuse or neglect
• To report reactions to medications or problems with products
• To notify people of recalls of products they may be using
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law
• To notify the appropriate government authority when required or authorized by law when an incident takes place at the Hospital that may affect your health and safety

Coroners and Medical Examiners: We may release medical information to a coroner or medical examiner when an investigation of a death is being conducted.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities so long as such disclosures are consistent with New York State law and policy.

Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or so they may conduct special investigations, so long as such disclosures are consistent with New York State law and policy.

Inmates: If you are an inmate of a correctional facility, we may disclose medical information necessary for making a determination regarding your health care, security, safety or ability to participate in programs when the chief administrative officer of the facility has made a request for it.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Right to Inspect and Copy: You have the right to inspect and obtain copies of the clinical record in the Hospital's possession, subject to certain limitations contained in the federal law and in the New York Mental Hygiene Law. If you are denied access to your medical information, you may request that the denial be reviewed in accordance with the requirements of the New York Mental Hygiene Law. You will receive a notice of the decision to deny and your right to seek a review of that decision.

You must submit your request to inspect or copy your clinical record in writing to the Medical Records Department. You may contact Ellen Markowitz at 914-763-8151, ext. 2355 if you have questions. If you request a copy of your record, we may charge the fee set under New York law for the copying.

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. You have the right to request an amendment for as long as the information is kept by or for the Hospital. We are not required to delete any information in your medical record but we will append the information you provide us to the record to ensure that it is accurate and complete. To request an amendment, your request must be made in writing and be submitted to the Medical Records Department. 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 medical information kept by or for the Hospital
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete

If we deny your request for an amendment, we will provide you with a timely written denial and the opportunity to provide the Hospital with a statement of disagreement with its denial. When your record is disclosed in the future, any material appended and, if applicable, your statement of disagreement, will be disclosed as well.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures". This is a list of certain types of disclosures of your medical information.

To request this list of accounting of disclosures, you must submit your request in writing to the
Medical Records Department. 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 cost 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. We will generally provide a copy of this Notice to you upon admission to the Hospital. You may ask us to give you a copy of this notice at any time by contacting the Privacy Officer or the Medical Records Department. You may obtain a copy of this Notice at our website; www.fourwindshospital.com.

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 a limit on the medical information we disclose about you to someone who is involved in your care. 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 Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use or disclosure or both; and (3) to whom you want the limits to apply, for example disclosures to a Hospital physician who may be consulted about your care for a second opinion while you are in the Hospital.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, by phone, or that we only contact you by mail at a certain address.

To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

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 on the first page in the top right-hand corner. In addition, each time you are admitted to the Hospital for treatment as an inpatient or outpatient, we will offer you a copy of the current Notice in effect.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. To file a complaint, contact the Hospital's Privacy Officer, Monica Broderick at 914-763-8151, ext. 2349. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION:

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to Hospital will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization at any time by notifying the Privacy Officer or the Medical Records Department in writing. If you revoke your authorization, 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 records of the care provided to you in the Hospital.

Date:______________________________

Signature of Patient or Legal Guardian: _______________________________________

Print Name:___________________________________

Witness:______________________________________