Patient Privacy Practices Notice


This notice describes how medical information about you may be used and shared with others. It also explains how you can inspect and get copies of your own medical information.

If you have any questions about this notice or would like further information, please contact us by calling 212-430-2800 or email info@OpenLinesNY.com

Table of Contents

WHY ARE YOU GETTING THIS NOTICE?

WHO FOLLOWS THE POLICIES IN THIS NOTICE?

WHAT HEALTH INFORMATION IS PROTECTED?

SUMMARY OF THIS NOTICE

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

1. Treatment, Payment, and Business Operations
2. Family and Friends
3. Research
4. Completely De-identified or Partially De-identified Information
5. Incidental Disclosures
6. Public Need
7. Workers’ Compensation
8. Coroners, Medical Examiners, and Funeral Directors
9. Organ and Tissue Donation

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

1. Your Right To Inspect and Obtain Copies of Your Records
2. Your Right To Amend Records
3. Your Right to An Accounting of Disclosures
4. Your Right to Request Additional Privacy Protections
5. Your Right to Request Confidential Communications

REQUEST FOR ACKNOWLEDGMENT

CONTACT INFORMATION


WHY ARE YOU GETTING THIS NOTICE?
Open Lines Speech and Communication PLLC (referred to as “our Practice” or “the Practice” in this notice) is required by federal and state law to protect the privacy of health information that may reveal your identity. We are also required to provide you with a copy of this notice. It describes the health information privacy practices of our Practice, our medical staff, and affiliated providers who work together to provide services with our Practice.

We will ask you to sign an “acknowledgment” indicating that you have been provided with this notice.

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WHO FOLLOWS THE POLICIES IN THIS NOTICE?
The privacy practices described in this notice are followed by:

• Any health care professional who treats you at our office, in a school, or in your home.

• All employees, medical staff, trainees, students, and volunteers who work at our office, in schools or in your home..

This notice refers to practices of our Practice and medical staff, while you are a patient of the Practice. The privacy practices described in this notice do not apply to members of our medical staff or other members of our workforce when they treat you while working for other practices or medical facilities, in which case treatment falls under the privacy policy of the facility where treatment is provided.

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WHAT HEALTH INFORMATION IS PROTECTED?
We are committed to protecting the privacy of information we gather about you while providing health-related services. Some examples of protected health information are:

• Information indicating that you are a patient of the Practice or that you are receiving treatment or other health-related services from our Practice;

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

• Information about health care products or services you have received or may receive in the future (such as an evaluation); or

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

when combined with:
•Demographic information (such as your name, address, or insurance status);

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

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

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SUMMARY OF THIS NOTICE

This summary includes references to sections that you may read for additional information.

1. Written Authorization Requirement.
We are generally required to obtain your written authorization before we share your health information with others. However, we may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations without your written authorization. (See section

1 below—Treatment, Payment, and Business Operations.)

2. Authorizing Transfer of Your Records.
You may request that we transfer your records to another person or organization by completing a written authorization form. This form will specify what information is being released, to whom, and for what purpose. The authorization will have an expiration date.

3. Canceling Your Written Authorization.

If you provide us with written authorization, you may revoke, or cancel, it at any time, except to the extent that we have already relied upon it. To revoke a written authorization, please write to the Executive Director.

4. Exceptions to Written Authorization Requirement.
There are some situations in which we do not need your written authorization before using your health information or sharing it with others. They include:

Treatment, Payment, and Business Operations. As mentioned above, we may use your health information or share it with others in order to treat you, obtain payment for that treatment, and run our business operations. (See section 1 below).

Patient Directory. If you do not object, we will include information about you in our Patient Directory. Information from the Patient Directory is given out when a person calls and asks for you by name. (See section 2a below).

Family and Friends. If you do not object, we will share information about your health with family and friends involved in your care. (See section 2b below).

Research. Although we will generally try to obtain your written authorization before using your health information for research purposes, there may be certain situations in which we are not required to obtain your written authorization. (See section 3 below).

De-Identified Information. We may use or disclose your health information if we have removed any information that might identify you. When all identifying information is removed, we say that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” information if the person who will receive it agrees in writing to protect your privacy when using the information. (See section 4 below).

Emergencies or Public Need. We may use or disclose your health information in an emergency or for important public health needs. For example, we may share information about you with public health officials at the New York State or city health departments who are authorized to investigate and control the spread of diseases. (See section 6 below).

5. How To Access Your Health Information.
You generally have the right to inspect and get copies of your health information. (See section 1 below).

6. How To Correct Your Health Information.
You have the right to request that we amend your health information if you believe it is inaccurate or incomplete. (See section 2 below)

7. How To Identify Others Who Have Received Your Health Information.
You have the right to receive an “accounting of disclosures.” This is a report that identifies certain persons or organizations to which we have disclosed your health information. All disclosures are made according to the protections described in this Notice of Privacy Practices. Many routine disclosures we make (for example, for treatment, payment, or business’s operations) will not be included in this report. However, it will identify any non-routine disclosures of your information. (See section 3 below)

8. How to Request Additional Privacy Protections.
You have the right to request further restrictions on the way we use your health information or share it with others. However, we are not required to agree to the restriction you request. If we do agree with your request, we will be bound by our agreement. (See section 4 below)

9. How To Request More 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. We will try to accommodate all reasonable requests. (See section 5 below)

10. 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 health information. Parents and guardians will generally have the right to control the privacy of health information of minors unless the minors are permitted by law to act on their own behalf.

11. How to Learn about Special Protections for HIV, Mental Health, and Genetic Information.
Special privacy protections apply to HIV-related information, mental health information, psychotherapy notes, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. (See the Appendix below)

12. How To Obtain A Copy of This Notice.
If you have not already received one, you have the right to a paper copy of this notice. You may request a paper copy at any time, even if you have previously agreed to receive this notice electronically. Just call us to request a copy: 212-430-6800. You may also obtain a copy of this notice from our web site at OpenLinesNY.com/privacy.html or by requesting a copy at your next visit.

13. How To Obtain A Copy of Revised Notice.
We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. We will post any revised notice in our waiting room. You will also be able to obtain your own copy of the revised notice by accessing our web site at OpenLinesNY.com/privacy.html, or calling 212-430-6800. You may also ask for one at the time of your next visit. We are required to abide by the terms of the notice that is currently in effect.

14. 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 United States Department of Health and Human Services. To file a complaint with us directly, please complete our online Anonymous Complaint Reporting Form: http://openlinesny.com/complaint/ . You may also file a complaint by phone, fax, email or letter addressed to Dr. Jessica Galgano (Executive Director) and submitted to:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Phone: (212) 430-6800
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

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

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HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION


1. Treatment, Payment, and Business Operations
We may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations.

a. Treatment.
We may share your health information with employees at the Practice who are involved in taking care of you. They may, in turn, use that information to diagnose or treat you. A clinician may share your health information with another clinician at the Practice to determine how to diagnose or treat you. All Open Lines Speech and Communication PLLC employees and volunteers have signed comprehensive Protected Health Information (PHI) Agreements agreeing to protect patient confidentiality. We may also share your health information with other doctors who referred you to us and/or to whom you have been referred for further health care. In situations where applicable, we may also share your child’s health information with relevant teachers, school administrators, or New York City Department of Education officials.

b. Payment.
We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company. This will help us obtain reimbursement after we have treated you, or determine whether your health insurance will cover your treatment. We might also need to inform your health insurance company about your health condition in order to obtain pre-approval for your treatment, such as admitting you to the Practice for a particular type of surgery. Finally, we may share your information with other health care providers and payers for their payment activities.

c. Business Operations.
We may use your health information or share it with others in order to conduct our business operations. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use it to educate our staff or health care students on how to improve the care they provide for you. We may also share your health information with other health care providers, who are required by federal law to protect the privacy of your health information, to help them with their business operations. For example we might share your insurance information with an audiologist or a doctor’s office if they need that information for their own quality assessment purposes.

d. Appointment Reminders, Treatment Alternatives, Benefits, and Services. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services at our facility. 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.

e. Business Associates.
We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company.

Another example is that we may share your health information with an insurance company, law firm, or a risk management organization in order to obtain professional advice about how to manage risk and legal liability, including insurance or legal claims. We may also share your health information with an accounting firm in order to obtain advice on legal compliance.

If we do disclose your health information to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your health information.

g. Communications Via E-Mail
In order to communicate information needed to treat you, obtain payment for services, or conduct our business operations, our staff may communicate information about you via email. However, you will not be contacted by email unless we have obtained your permission to do so, or we are responding to an inquiry that you initiated via email.

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2. Family and Friends

We may share your health information with family and friends involved in your care, without your written authorization. We will give you an opportunity to object unless there is insufficient time because of a medical emergency. In a medical emergency, we will discuss your preferences with you as soon as the emergency is over. We will follow your wishes unless we are required by law to do otherwise.

If you do not object, 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 about your location and general condition here at the Practice. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.

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3. 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 written authorization. To do this, we are required to obtain approval through a special process to ensure that research without your written 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 written 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.

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4. Completely De-identified or Partially De-identified Information.
We may use and disclose your health information if we have removed any information that has the potential to identify you, so that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, web site address, or driver’s license number).

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5. Incidental Disclosures
While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

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6. Public Need
a. 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 notice is required by law.

b. Public Health Activities.
We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials who are responsible for controlling disease, injury, or disability.

We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease, if a law permits us to do so. And finally, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam. This could happen if we were to discover that you have a work-related injury or disease that your employer must know about in order to comply with employment laws.

c. Victims of Abuse, Neglect, or Domestic Violence.
We may release your health information to a public health 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 such abuse, neglect, or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.

d. Health Oversight Activities.
We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facility. These government 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.

e. Product Monitoring, Repair, and Recall.
We may disclose your health information to a person or company that is regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

f. Lawsuits and Disputes.
We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.

g. Law Enforcement.
We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders 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 general written 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 interests;

• 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 treatment.

h. To Avert A Serious And Imminent Threat to Health or Safety.
We may use your health information or share it with others when necessary to prevent a serious and imminent 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: 1) if you tell us that you participated in a violent crime that may have caused serious physical harm to another person, or 2) if we determine that you escaped from lawful custody (such as a prison or mental health institution).

i. National Security and Intelligence Activities or Protective Services.
We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

j. 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.

We may also release health information about foreign military personnel to the appropriate foreign military authority.

k. Inmates and Correctional Institutions.
If you are an inmate, or if you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers. This may happen if it is 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 persons involved in supervising or transporting inmates.

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7. Workers’ Compensation.
We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

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8. Coroners, Medical Examiners, and Funeral Directors.
In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.


9. 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.

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YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that 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.

1. Your Right To Inspect and Obtain Copies of Your Records.
You have the right to inspect and obtain a 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.

a. How to Make Your Request.
To inspect or obtain a copy of your health information, please submit your request in writing to Dr. Jessica Galgano (Executive Director) . You may submit this written request by mail, email or fax:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

b. Cost.
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.

c. Response Time.
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.

d. If Your Request is Denied.
Under certain very limited 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 United States 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.

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2. Your Right To Amend 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.

a. How to Make Your Request.
To request an amendment, please write to the Executive Director. Your request should include the reasons why you think we should make the amendment.

b. Response Time.
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.

c. If Your Request is Denied.

If we deny part or your entire 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 United States Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

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3. Your Right To An Accounting Of Disclosures.
You have a right to request an “accounting of disclosures.” This report identifies certain other persons or organizations to whom we have disclosed your health information. The accounting does not include routine disclosures we have made for treatment, payment and operations. It also does not include disclosures we have made with your written authorization.

a. How to Make Your Request.
To request an accounting of disclosures, please write to Jessica Galgano (Executive Director). Your request must state a time period within the past six years for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2004 and January 1, 2005. You may submit this written request by mail, email or fax:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

b. Cost.
You have a right to receive one accounting every 12-months without charge. However, we may charge you for the cost of providing any additional accounting 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.

c. Response Time.
Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting 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. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.

d. What is NOT Included in the Accounting of Disclosures?

An accounting of disclosures does not describe the ways that your health information has been shared within and between the Practice and the facilities listed at the beginning of this notice. We are not required to include this information as long as all other protections described in this Notice of Privacy Practices have been followed.

An accounting of disclosures also does not include information about the following disclosures:

• Disclosures we made to you or your personal representative;

• Disclosures we made pursuant to your written authorization;

• Disclosures we made for treatment, payment, or business operations;

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

• Disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by);

• Disclosures of limited portions of partially de-identified information, for purposes of research, public health, or our business operations;

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

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

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4. Your Right To Request Additional Privacy Protections
You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our business operations. You may also 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.

a. How to Make Your Request.
To request restrictions, please write to Jessica Galgano (Executive Director). 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. You may submit this written request by mail, email or fax:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

b. We are Not Required to Agree.
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. In other cases, we will need your permission before we can revoke the restriction.

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5. Your 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 by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work.

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How to Make Your Request.
To request more confidential communications, please write to Jessica Galgano (Executive Director). We 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.

You may submit this written request by mail, email or fax:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

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REQUEST FOR ACKNOWLEDGMENT
Please sign the Notice of Privacy Practices Acknowledgment in the Open Lines Speech and Communication registration packet. By signing the Notice of Privacy Practices Acknowledgment, you acknowledge that you have been provided access to this notice.

 

CONTACT INFORMATION

Address:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023

Phone: (212) 430-6800

Secure Fax: (212) 430-6550

Emails: Care@OpenLinesNY.com

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APPENDIX:
CONFIDENTIALITY OF HIV-RELATED INFORMATION, MENTAL HEALTH INFORMATION AND PSYCHOTHERAPY NOTES, AND GENETIC INFORMATION

The privacy and confidentiality of some types of information maintained by this Practice is protected by Federal and State law and regulations that go beyond the protections described in this general Notice of Privacy Practices. This information includes:

HIV-Related Information
Mental Health Information
Psychotherapy Notes
Genetic Information

If there is any conflict between the general Notice of Privacy Practices and this notice, the protections described in this notice will apply instead of the protections described in the general Notice of Privacy Practices.

HIV-RELATED INFORMATION
Confidential HIV-related information is any information indicating that you had an HIV-related test, have HIV-related illness or AIDS, or have an HIV-related infection, as well as any information which could reasonably identify you as a person who has had a test or has HIV infection.

Under New York State law, confidential HIV-related information can only be given to persons allowed to have it by law, or persons you have allowed to have it by signing a specific authorization form. You can ask to see a list of people who can be given confidential HIV-related information by law without a specific authorization form.

With your written consent, confidential HIV-related information about you may be used by personnel within the Practice who need the information to provide you with direct care or treatment, to process billing or reimbursement records, or to monitor or evaluate the quality of care provided at the Practice. Generally this Practice may not reveal to a person outside of the Practice any confidential HIV-related information that the Practice obtains in the course of treating you, unless:

• We obtain your written permission on a specific authorization form;

•The disclosure is to a person who is authorized under applicable law to make health care decisions on your behalf and the information disclosed is relevant to those health care decisions;

• The disclosure is for treatment or payment purposes, so long as the Practice has obtained your general consent to such disclosures;

• The disclosure is to an external agent of the Practice who needs the information to provide you with direct care or treatment, to process billing or reimbursement records, or to monitor or evaluate the quality of care provided at the Practice. In such cases, we will ordinarily obtain your general consent and have an agreement with the agent to ensure that your confidential HIV-related information is protected as required under
Federal and State confidentiality laws and regulations;

• The disclosure is required by law or court order;

• The disclosure is to an organization that procures body parts for transplantation;

• You receive services under a program monitored or supervised by a federal, state or local government agency and the disclosure is made to such government agency or other employee or agent of the agency when reasonably necessary for the supervision, monitoring, administration of provision of the program’s services;

• the Practice is required under Federal or State law to make the disclosure to a health officer;

• The disclosure is required for public health purposes;

• If you are an inmate at a correctional facility and disclosure of confidential HIV-related information to the medical director of such facility is necessary for the director to carry out his or her functions;

• For decedents, the disclosure is made to a funeral director who has taken charge of the decedent’s remains and who has access in the ordinary course of business to confidential HIV-related information on the decedent’s death certificate;

• The disclosure is made to report child abuse or neglect to appropriate State or local authorities.

Violation of these privacy regulations may subject the Practice to civil or criminal penalties. Suspected violations may be reported to appropriate authorities in accordance with Federal and State law.

MENTAL HEALTH INFORMATION
With your written consent, mental health information about you may be used by personnel within the Practice (or its business associates) in connection with their duties to provide you with treatment, obtain payment for that treatment, or conduct the Practice’s normal business operations. Generally the Practice may not reveal mental health information about you to other persons outside of the Practice, except in the following situations:

• When the Practice has obtained your written permission on a specific authorization form;

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

• To government agencies or private insurance companies in order to obtain payment for services we provided to you;

• To comply with a court order;

• To appropriate persons who are able to avert a serious and imminent threat to the health or safety of you or another person;

• To appropriate government authorities to locate a missing person or conduct a criminal investigation as permitted under Federal and State confidentiality laws and regulations;

• To other licensed Practice emergency services as permitted under Federal and State confidentiality laws;

• To the mental hygiene legal service offered by the State;

• To attorneys representing patients in an involuntary hospitalization proceeding;

• To authorized government officials for the purpose of monitoring or evaluating the quality of care provided by the Practice or its staff;

• To qualified researchers without your specific authorization when such research poses minimal risk to your privacy;

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

• If you are an inmate, to a correctional facility which certifies that the information is necessary in order to provide you with health care, or in order to protect the health or safety of you or any other persons at the correctional institution.

PSYCHOTHERAPY NOTES
Psychotherapy notes are notes by a mental health professional that document or analyze the contents of a conversation during a private counseling session – or during a group, joint, or family counseling session. If these notes are maintained separate from the rest of your medical records, they can only be used and disclosed as follows.

In general, psychotherapy notes may not be used or disclosed without your special written authorization, except in the following circumstances.

With your general written consent, psychotherapy notes about you may be used and disclosed in the following situations:

• The mental health professional who created the notes may use them to provide you with further treatment;

• The mental health professional who created the notes may disclose them to students, trainees, or practitioners in mental health who are learning under supervision to practice or improve their skills in group, joint, family, or individual counseling;

• The mental health professional who created the notes may disclose them as necessary to defend his or herself, or the Practice, in a legal proceeding initiated by you or your personal representative;

Psychotherapy notes may be used and disclosed without your consent or other authorization in the following situations to comply with the law or meet an important public need:

• The mental health professional who created the notes may disclose them as required by law;

• The mental health professional who created the notes may disclose the notes to appropriate government authorities when necessary to avert a serious and imminent threat to the health or safety of you or another person;

• The mental health professional who created the notes may disclose them to the United States Department of Health and Human Services when that agency requests them in order to investigate the mental health professional’s compliance, or the Practice’s compliance, with Federal privacy and confidentiality laws and regulations; and

• The mental health professional who created the notes may disclose them to medical examiners and coroners if necessary to determine your cause of death.

All other uses and disclosures of psychotherapy notes require your special written authorization.

GENETIC INFORMATION
A genetic test means a laboratory test of human DNA, chromosomes, genes or gene products to diagnose the presence of a genetic variation linked to a predisposition to a genetic disease or disability in the individual or the individual’s offspring. A genetic test does not include any test of blood or other medically prescribed test in routine use that has been or may be found to be associated with a genetic variation unless it is conducted purposely to identify such genetic information.

All records, findings and results of any genetic test performed on any person shall be confidential and generally shall not be disclosed without the written informed consent of the person to whom such genetic test relates.

With your consent, the results of your genetic test may be disclosed to a health insurer or health maintenance organization if the information disclosed is reasonably required for purposes of claims administration. However, any further distribution of the information within the insurer or to other recipients will require your written consent in each case.

Information derived from your genetic test may not be incorporated into the records of a non-consenting individual who may be genetically related to you, and no inferences may be drawn, used or communicated regarding the possible genetic status of the non-consenting individual.

The results of your genetic test may be disclosed to specified individuals without your consent if such disclosure is required by a court order or otherwise required or authorized by State law.

Your genetic information shall not be released to any person or organization not specifically authorized by you without additional written consent. the Practice is aware that an individual who might ordinarily be authorized to act as your personal representative, such as your spouse or a parent, may not be considered a personal representative for purposes of accessing your genetic information. For example, if you have authority to provide written consent on your own, your genetic information should not be released to your parent or guardian unless you have specifically authorized such a disclosure. If your parent or guardian is authorized under law to sign the written consent form on your behalf, the results of the test may be provided to him or her.

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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 directly, please complete our online Anonymous Complaint Reporting Form: http://openlinesny.com/complaint/ . You may also file a complaint by phone, fax, email or letter addressed to Dr. Jessica Galgano (Executive Director) and submitted to:

Open Lines Speech and Communication PLLC
Attn: Jessica Galgano
252 W 76th St, Suite 1A
New York, NY 10023
Phone: (212) 430-6800
Secure Fax: (212) 430-6550
Email: Care@OpenLinesNY.com

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

If you experience discrimination because of the release of confidential HIV-related information, you may contact the New York State Division of Human Rights at (212) 566-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.

If you have any questions about the policies in this Appendix or would like further information, please contact us at 212-430-6800.

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Other Questions?
Contact us at (212) 430-6800