notice of privacy practices

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.

Our Duties
Nascentia Health is required by law to maintain the
privacy of your medical information and to provide you with notice of our legal duties and privacy
practices. We are required to abide by the terms of this Notice of Privacy Practices. Nascentia reserves
the right to change these terms, and any changes made will be effective for all medical information
we maintain. A copy of the revised notice will be available from your nurse or therapist. You may
also address questions regarding our privacy practices, your privacy rights, or requests for
additional information regarding your privacy using the contact information listed at the end of this
Notice.

Permitted Uses
Nascentia may use and disclose identifiable health information for specific reasons:

• Treatment: We will use your medical/health information to treat you as your doctor orders, or
to assist others in your treatment. We will provide your doctor or other health care provider with
results of treatment, progress, or changes in your condition. With your permission or when
otherwise appropriate, Nascentia may disclose health information to a friend or family member who
assists in your care.

• Payment: We will use your medical/health information to bill your insurance company, you
directly, or another person who may be responsible for payment of your account. We may
contact your health insurer to determine whether you are eligible to receive services, and we
may provide your insurer with details regarding your treatment, in order to bill and collect
payment for the services you receive from us.

• Health Care Operations: Nascentia may use and disclose your identifiable health information to
operate our business. For example, we may use your health information to evaluate the quality
of care you receive from us, to contact you and remind you of visits, to conduct business
planning activities. We may also select your billing information for review by internal compliance
personnel or by external auditors. We may contact you as part of a fund raising effort. You
have the right to choose not to receive fund raising communications.

• When Required By Law: Nascentia will use and disclose your identifiable health information when
we are required to do so by federal, state or local law, such as:

  1. To public health agencies or authorities;
  2. For government oversight such as review by Medicare or a related agency;
  3. For judicial or administrative proceedings, in response to a court order, subpoena,discovery request, or other lawful process;
  4. To law enforcement officials upon request;
  5. When necessary to reduce or prevent serious threats to your health and safety, or the health and safety of another individual or to the public;
  6. To appropriate command authorities of military personnel;
  7. To Workers Compensation and similar programs.

Patient Rights
You have the following rights regarding the information that we maintain about you:

Confidential Communications: You may ask that we communicate with you in a particular way, or
at a certain location, for example, that we contact you at work, rather than at home. Your request
must be in writing, specifying your request. Nascentia will accommodate reasonable requests; you do
not need to give a reason for your request.

Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your
identifiable health information. We are not required to agree to your request unless specific
circumstances apply. If we do agree to it, we will abide by your request except when otherwise
required by law, in emergencies, or when this information is necessary to treat you. Your request
must be in writing, describing the information that you want restricted; must state whether you are
requesting to limit Nascentia’s use, disclosure or both; and state to whom you want the restriction to
apply.

Inspect and Copy: You have the right to inspect and obtain a copy of your medical information
maintained in Nascentia records, including medical and billing records. Your request must be in writing,
and Nascentia may charge you a fee for this service. If we deny your request, we will send you a written
denial. If this happens, you may request a review of the denial.

Amendment: You may ask us to amend your health information if you believe that it is incorrect or
incomplete. Your request must be in writing and must include a reason to support your request.
Your request may be denied if we believe that the information is complete and accurate, if the
information is not part of the medical record that you would be permitted to inspect or copy, or if
Nascentia did not create the information.

Accounting of Disclosures: You may request a list of certain disclosures that we have made of your
health information during a stated time period. The time period can be up to six years, but does not
include dates before April 14, 2003. The first request within a 12 month period is free, but Nascentia may
charge you for additional requests within the same 12 month period.

Copy of this Notice: You are entitled to receive a paper copy of this Notice of Privacy Practices, and
you may ask for one at any time. You may also obtain a copy from our website at
http://www.nascentiahealth.org/

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a
complaint directly with Nascentia using the contact information below. You may also file a complaint with
the Department of Health and Human Services Office of Civil Rights at 1-866-627-7748. You will
not be penalized for complaining.

Authorization
Nascentia will obtain your written authorization for uses and disclosures that are not identified by this
notice, or permitted by applicable law. Any authorization that you provide regarding the use and
disclosure of your identifiable health information may be revoked in writing at any time. After you
revoke your authorization, we will no longer disclose information for the reasons described in the
authorization.

CONTACT INFORMATION
To make a request, ask for information, revoke an authorization, or file a complaint, please contact
Nascentia in writing to the following:

Nascentia Health
Medical Records Department
1050 West Genesee Street
Syracuse, New York 13204
Telephone (315) 476-3101

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