Effective Date: 04/14/03
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
PLEASE REVIEW IT CAREFULLY. THE
PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
If you have any questions about this
notice please contact our privacy officer at (631) 726-8200.
We are required by applicable
federal and state law to maintain the privacy of your medical information. We
are also required to give you this notice about our privacy practices, our
legal duties, and your rights concerning your medical information. We must
follow the privacy practices that are described in this notice while it is in
effect. This notice takes effect 04/14/2003, and will remain in effect
until we replace it.
We reserve the right to change our
privacy practices and the terms of this notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the
changes in our privacy practices and the new terms of our notice effective for
all medical information that we maintain, including medical information we
created or received before we made the changes. Before we make a significant
change in our privacy practices, we will change this notice and make the new
notice available upon request.
You may request a copy of our notice
at any time. For more information about our privacy practices, or for
additional copies of this notice, please contact us using the information
listed at the end of this notice.
Will Follow This Notice
This notice describes our hospital’s
practices and those participants listed below in our organized health care
arrangement. As such, we may share your medical information and the medical
information of others we service with each other as needed for treatment,
payment or health care operations relating to our organized health care
This notice does not imply any joint venture or any other
special association or legal relationship between the hospital and its medical
staff. This notice is an administrative tool permitted by federal law allowing
the hospital and medical staff to tell you about common privacy practices.
Along with the hospital, the following
participate in our organized health care arrangement:
- Members of our medical staff and their employees or
workforce who provide services or support to the physician at the
- Our employed physicians and their office staff.
and Disclosures of Medical Information
We use and disclose medical
information about you for treatment, payment, and health care operations. For
We may use or disclose your medical information to a
physician or other health care provider in order to provide treatment to you.
We may use and disclose your medical information to obtain
payment for services we provide to you. We may disclose your medical
information to another health care provider or entity subject to the federal
and state Privacy Rules so they can obtain payment.
Health Care Operations:
We may use and disclose your medical information in
connection with our health care operations. These uses are necessary to make
sure that all our patients receive quality care.
Some examples are:
On Your Authorization:
- Review of our treatment or services to evaluate the
performance of our staff providing your care;
- Sending you a satisfaction survey;
- Review of information about many of our patients to
determine if additional services should be added or perhaps are no longer
needed;information may be given to our doctors, nurses,
medical and health care students, and other personnel to be used for
education and learning purposes;
- We may remove information that identifies you from the
medical information so others may use it for studies in health care
delivery without learning who the patients are;
- And we may disclose your medical information to another
provider who has a relationship with you and is subject to the same
Privacy rules, for their health care operation purposes.
You may give us written authorization to use your medical
information or to disclose it to anyone for any purpose. If you give us an authorization,
you may revoke it in writing at any time. Your revocation will not affect any
use or disclosures permitted by your authorization while it was in effect.
Unless you give us a written authorization, we cannot use or disclose your
medical information for any reason except those described in this notice.
We may use and disclose medical information to contact you
as a reminder that you have an appointment for treatment or medical care at the
To Your Family and Friends:
Unless you object, we may disclose your medical information
to a family member, friend or other person to the extent necessary to help with
your health care or with payment for your health care.
If you are not present, or in the
event of your incapacity or an emergency, we will disclose your medical
information based on our professional judgment of whether the disclosure would
be in your best interest.
We will also use our professional
judgment and our experience with common practice to allow a person to pick up
filled prescriptions, medical supplies, x-rays or other similar forms of
We may use your name, your location in our facility, your
general medical condition, and your religious affiliation in our facility directories.
We will disclose this information to members of the clergy and, except for
religious affiliation, to other persons who ask for you by name. We will
provide you with an opportunity to restrict or prohibit some or all disclosures
for facility directories unless emergency circumstances prevent your
opportunity to object.
In addition, we may disclose medical information about
you to an organization assisting in a disaster relief effort so your family can
be notified about your condition and location.
By Law or Special Circumstances:
We may use or disclose your medical information as
authorized by law for the following purposes deemed to be in the public
interest or benefit:
Health Related Benefits and
- as required by law;for public health activities, including disease and
vital statistic reporting, child abuse reporting, FDA oversight, and to
employers regarding work-related illness or injury;
- to report adult abuse, neglect, or domestic violence;
- to health oversight agencies;In response to court and administrative orders and other
- to law enforcement officials after receiving subpoenas
and other lawful processes, concerning crime victims, suspicious deaths,
crimes on our premises, reporting crimes in emergencies, and for purposes
of identifying or locating a suspect or other person;
- to coroners, medical examiners, and funeral directors;
- to organ procurement organizations;
- to avert a serious threat to health or safety;
- in connection with certain research activities;
- to the military and to federal officials for lawful
intelligence, counterintelligence, and national security activities;
- to correctional institutions regarding inmates;
- and as authorized by state worker's compensation laws
We may use your medical information
to contact you with information about health-related benefits and services or
about treatment alternatives that may be of interest to you. We may disclose
your medical information to a business associate to assist us in these
We may use or disclose your medical
information to encourage you to purchase or use a product or service by
face-to-face communication or to provide you with promotional gifts.
Use and Disclosure of Certain Types
of Medical Information:
For certain types of medical information we may be
required to protect your privacy in ways more strict than we have discussed in
this notice. We must abide by the following rules for our use or disclosure of
certain types of your medical information:
We may not disclose HIV information unless required by law,
pursuant to an authorization or the disclosure is to you or your personal
representative; to medical personnel in an emergency to the extent necessary to
protect your health or safety; to a person whom the facility believes has been
exposed to HIV infection, but only such information shall be disclosed as
related to HIV information; or, to a law enforcement officer who has in the
course of his or her duties been exposed to your blood or bodily fluid in such
a manner that risk of infection exists, but only such information shall be
disclosed as related to HIV information or the hepatitis B virus.
Alcohol and Drug Abuse Information:
We may not disclose your medical information that contains
alcohol and drug abuse information except to you, your personal representative
or pursuant to an authorization or as may otherwise be allowed by law.
Rights Regarding Medical Information About You
Right to Inspect and Copy:
You have the right to look at or get copies of your medical
information, with limited exceptions. You must make a request in writing to
obtain access to your medical information. You may obtain a form to request
access by using the contact information listed at the end of this notice. You
may also request access by sending us a letter to the address at the end of
this notice. If you request copies, we will charge you a fee for copying and
postage if you want the copies mailed to you. Contact us using the information
listed at the end of this notice for a full explanation of our fee structure.
We may deny your request to inspect
and copy in very limited circumstances as allowed by law. If you are denied
access to your medical information, you may request that the denial be
reviewed. Another licensed health care professional chosen by the hospital will
review your request and the denial. The person conducting the review will not
be the person who denied your request. We will comply with the outcome of the
You have the right to receive a list of instances in which
we or our business associates disclosed your medical information for purposes
other than treatment, payment, health care operations, as authorized by you,
and for certain other activities, since April 14, 2003. You must make a
request in writing to request a listing of disclosures. You may obtain a form
to request the accounting by using the contact information at the end of this
If you request this accounting more
than once in a 12-month period, we may charge you a reasonable, cost-based fee
for responding to these additional requests. Contact us using the information
listed at the end of this notice for a full explanation of our fee structure.
You have the right to request that we place certain
restrictions on our use or disclosure of your medical information. We are not
required to agree to these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency). Any agreement to additional
restrictions must be in writing. You may obtain a form to request additional
restrictions on the use or disclosure of your medical information by using the
contact information listed at the end of this notice. We will not be bound to
the restrictions unless our agreement is signed by you and the appropriate
You have the right to request that we communicate with you
about your medical information by alternative means or to alternative
locations. For example, you might request that we contact you at work or by
mail. You must make your request in writing. You may obtain a form to request
alternative communications by using the contact information listed at the end
of this notice. We must accommodate your request if it is reasonable,
specifies the alternative means or location, and provides satisfactory
explanation how payments will be handled under the alternative means or
location you request.
If you feel that medical information we have about you is
incorrect or incomplete, you may ask us to amend the information. Your request
must be in writing, and it must explain why the information should be amended.
You may obtain a form to request an amendment by using the contact information
listed at the end of this notice. We may deny your request if we did not create
the information you want amended and the individual who provided the
information remains available or for certain other reasons. If we deny your
request, we will provide you a written explanation. You may respond with a
statement of disagreement to be attached to the information you wanted amended.
If we accept your request to amend the information, we will make reasonable
efforts to inform others, including people you name, of the amendment and to
include the changes in any future disclosures of that information.
If you receive this notice on our web site or by electronic
mail (e-mail), you are entitled to receive this notice in written form. Please
contact us using the information listed at the end of this notice to obtain
this notice in written form.
If you want more information about
our privacy practices or have questions or concerns, please contact us using
the information listed at the end of this notice.
If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made
about access to your medical information or in response to a request you made
to amend or restrict the use or disclosure of your medical information or to
have us communicate with you by alternative means or at alternative locations,
you may complain to us using the contact information listed at the end of this
notice. You also may submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy
of your medical information. We will not retaliate in any way if you choose to
file a complaint with us or with the U.S. Department of Health and Human
240 Meeting House Lane
Southampton, New York 11968
Telephone: (631) 726-8200
THIS NOTICE IS YOUR COPY TO RETAIN
FOR ANY FUTURE QUESTIONS OR CONCERNS REGARDING THE USE OF YOUR PROTECTED HEALTH