BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER
592 Rockaway Avenue Brooklyn, New York 11212

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER is required by law to maintain the privacy of your protected health information and to provide you with notice of its legal duties and privacy practices with respect to protected health information. USES AND DISCLOSURES REQUIRING A CONSENT. Except where a use or disclosure is required by law or necessary to provide service to you or to provide for medical audits by the Department of Health and Human Services, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER will use or disclose your protected health information, even where a specific written authorization is not required, only pursuant to your written consent. You may revoke your consent at any time except to the extent BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER has acted in reliance on it.

USES AND DISCLOSURES REQUIRING AN AUTHORIZATION. Except as otherwise provided in this Notice, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER will use and disclose protected health information only upon your specific written authorization relating to the protected health information to be used or disclosed. You may revoke such an authorization at any time except to the extent BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER has acted in reliance on it.

USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose your protected health information without your specific written authorization for its own treatment, payment, or health care operations and may disclose protected health information for treatment activities of a health care provider, to another health care organization or provider for payment activities of the provider that receives the information, or, under certain circumstances, to another health care organization for health care operations activities of that organization.

Treatment means provision, coordination, or management of a patients care by a health care provider or providers, including coordination or management of a patients care with a third party, consultation between health care providers about a patient, or referral of a patient from one provider to another. For example, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information to its own or other health care providers who need such information for a patients care.

Payment means a health care providers activities to provide or receive reimbursement for health care services provided to a patient, including, for example, determinations of eligibility or coverage; billing, claims management, collection activities, and related health care data processing; review of health care services for medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; utilization review activities; and certain reimbursement-related disclosures to consumer reporting agencies. For example, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may send a bill to a patients insurer that includes information identifying the patient, the patients diagnosis, and the procedures and supplies used.

Health Care Operations include activities such as conducting quality assessment and improvement activities; population-based activities relating to improvement of health care; reviewing the competence or qualifications of health care professionals; conducting training programs for health care professionals; accreditation, certification, licensing, and credentialing activities; conducting or arranging for medical review, legal services, and auditing functions; business planning and development; and business management and general administrative activities. For example: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTERs quality improvement team may use information in a patients health record to assess the care and outcomes in the patients case and others like it in an effort to continually improve the quality and effectiveness of the care it provides. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may also disclose a patients health record with another health care provider who treated the patient for that providers quality assessment activities.

Appointment Reminders, Treatment Alternatives, and Other Health-Related Benefits: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may contact you to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.

Fund-Raising: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may contact you to raise funds for BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER.

OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may also use or disclose protected health information without your specific written authorization where permitted or required by law. The permitted and required uses and disclosures are described below.

With the Opportunity to Agree or Object. While the uses and disclosures described below may be done without your specific written authorization, you must usually be given an opportunity to agree or object.

Directory Information: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use a patients name, location at BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER, general condition, and religious affiliation in a patient directory for its facility. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose the directory information to members of the clergy and, except for a patients religious affiliation, to anyone who asks for a patient by name.

To Those Involved with a Patients Care: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose to a family member, other relative, close personal friend of a patient, or any other person identified by a patient, protected health information directly relevant to that persons involvement with the patients care or payment related to the patients care.

For Notification of a Patients Location, General Condition, or Death: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose protected health information to notify or assist in notifying a family member, a patients personal representative, or another person responsible for a patients care of a patients location, general condition, or death.

For Disaster Relief Purposes: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose protected health information to an organization authorized by law or by its charter to assist in disaster relief efforts for the purpose of coordinating notification to a family member, a patients personal representative, or another person responsible for a patients care of a patients location, general condition, or death.

Without the Opportunity to Agree or Object. So long as the privacy rule requirements are followed, the uses and disclosures described below may be done without your specific written authorization and without giving you an opportunity to agree or object.

Required by Law: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose protected health information to the extent the use or disclosure is required by law, complies with, and is limited to the relevant requirements of such law.

Public Health Activities: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information for a variety of public health activities. These include, for example, disclosure (i) to a public health authority authorized by law to collect or receive information for the prevention or control of disease, injury, or disability or to a public health or other authority authorized by law to receive reports of child abuse or neglect; (ii) to a person under the jurisdiction of the FDA regarding an FDA-regulated product or activity for which that person has responsibility for purposes related to the quality, safety, or effectiveness of the FDA-regulated product or activity; if authorized by law to do so, to someone who may have been exposed to a communicable disease; or to an employer about an employee to whom BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER provides health care at the employers request to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether the employee has a work-related illness or injury.

Abuse, Neglect, or Domestic Violence: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information about a patient whom BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER reasonably believes to be a victim of abuse, neglect, or domestic violence to a government authority authorized to receive this information to the extent such use or disclosure is required by law, complies with, and is limited to the relevant requirements of such law; where the patient agrees to the disclosure; or, under certain circumstances, where expressly authorized by law.

Health Oversight Activities: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for the oversight of the healthcare system, government benefit programs, or compliance with governmentally-regulated program standards or civil rights laws where health information is necessary to determine compliance. Where the patient is the subject of the investigation or activity, there are restrictions on when such information may be used or disclosed.

Judicial and Administrative Proceedings: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information in a judicial or administrative proceeding in response to a court or administrative tribunal order, or, so long as certain requirements are met, a subpoena, discovery request, or other lawful process not accompanied by a court or tribunal order.

Law Enforcement Purposes: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information for a law enforcement purpose to a law enforcement official under certain specified circumstances.

Coroners, Medical Examiners, and Funeral Directors: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information to coroners or medical examiners for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may also disclose protected health information to funeral directors as necessary to carry out their duties.

Organ Donation: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating donation and transplantation.

Research: So long as certain requirements are met, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information to researchers for reviews preparatory to research, for research on a decedent's information, and when the research has been approved by the Research Review Committee.

Threat to Health or Safety: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may, subject to certain exceptions and so long as certain requirements are met, use or disclose protected health information to designated organizations or individuals where necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or to identify or apprehend someone who may have caused serious physical harm to another person or who appears to have escaped from custody.

Other Specialized Government Functions: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may use or disclose protected health information in certain instances related to military and other specialized government functions, for example, for members of the armed forces, as deemed necessary by appropriate military command authorities.

Workers Ccompensation: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar legally-established programs.

OTHER RESTRICTIONS ON USE OR DISCLOSURE. Notwithstanding any statement elsewhere in this Notice, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER will not use or disclose protected health information in any way that is restricted or prohibited by law. Uses and disclosures to which this applies include:

Protected Health Information of Minor Patients: BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER is required by law not to disclose protected health information of minor patients to their parents or guardians under certain circumstances.

Protected Health Information Relating to Certain Diseases: Except where specifically required or permitted by law, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may not disclose a patient's protected health information relating to certain conditions, including HIV disease and substance abuse, without the patient's specific written authorization.

Psychotherapy Notes: Except for use by the originator of the psychotherapy notes for treatment or use or disclosure by BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER for its own training programs or to defend itself in a legal action or other proceeding brought by the patient, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may not use or disclose psychotherapy notes without the patient's specific written authorization.

Marketing: Except for face-to-face communication with a patient or to give the patient a gift of nominal value, BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may not use or disclose protected health information for marketing without the patient's specific written authorization.

PATIENT RIGHTS. You have the following rights concerning protected health information about you:

Right to Request Restrictions: You have the right to request restrictions on uses and disclosures of protected health information to carry out treatment, payment, or health care operations; to those involved with your care; or for notification of your location, general condition, or death. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER is not required to agree to the restriction.

Right to Confidential Communications: You have the right to receive reasonable accommodation of requests to receive communications of protected health information by alternative means or at alternative locations. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may not require an explanation from you as to the reason for the request.

Right of Access: With certain exceptions, you have the right of access to inspect and copy protected health information.

Right to Amend: You have the right to amend protected health information. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER may deny the request under certain circumstances, for example, if it determines that the information is accurate and complete.

Right to an Accounting: With certain exceptions, you have the right to receive an accounting of disclosures of protected health information. The right to an accounting does not include, for example, disclosures to carry out treatment, payment, or health care operations or pursuant to an authorization.

Right to Receive a Copy of this Notice: You have the right, upon request, to obtain a paper copy of this Notice from BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER.

CHANGES TO THIS NOTICE. BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER is required by law to abide by the terms of the Notice currently in effect.

BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that it maintains. Should BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTERs practices regarding protected health information change, the revised Notice will be made available to you at your request and will be posted in a clear and prominent location at your service site.

FOR MORE INFORMATION, TO REVOKE A CONSENT OR AUTHORIZATION, OR TO REPORT A PROBLEM.

For the procedure regarding exercising any of your rights under this Notice, or if you have questions or would like additional information about the matters covered by this Notice, you may contact the Health Information Manager at (718) 345 5000 ext105 Brownsville Multi Service Family Health Center. To revoke an existing consent or authorization, please contact the Health Information Manager at (718) 345 5000 ext. 105 at Brownsville Multi Service Family Health Center.

If you believe your privacy rights have been violated, you may file a complaint with BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER or with the Secretary of the United States Department of Health and Human Services. 26 Federal Plaza New York, New York 10278. To file a complaint with BROWNSVILLE MULTI SERVICE FAMILY HEALTH CENTER, please contact the Health Information Manager at (718) 345 5000 ext. 105 at Brownsville Multi Service Family Health Center.

All complaints must be submitted in writing. There will be no retaliation against you for filing a complaint.

EFFECTIVE DATE. April 14,2003