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 Carol Camenisch Simpson
Corporate Compliance Officer/Privacy Officer Phone: 845-708-2000 x 1481
Our Privacy Commitment to You:
At Jawonio, we understand that health information about you is personal and confidential. We
are committed to protecting your health information and sharing information only with those
who need to know and are allowed to see the information. We need to maintain certain
information about you to provide you with quality services and comply with law and regulation.
This Notice of Privacy Practices describes how we may use and disclose your protected health
information to carry out treatment, payment or health care operations and for other purposes that
are permitted or required by law. It also describes your rights to access and control your
protected health information. Protected Health Information, or “PHI,” is information about you,
including demographic information, that may identify you and that relates to your past, present
or future physical or mental health or condition, related health care services and payment for
We are required to abide by the terms of this Notice of Privacy Practices. We are also required
to notify you following a breach of unsecured health information. We may change the contents
of our notice at any time. The new notice will be effective for all protected health information
that we maintain. You may obtain any revised Notice of Privacy Practices by accessing our
website (www.jawonio.org), calling us and requesting that a revised copy be sent to you or
asking for one when meeting with staff. We will promptly revise and make available this Notice
whenever there is a material change to the uses or disclosures, your rights related thereto, our
legal duties, or other privacy practices stated in this Notice.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Based Upon Your Written Consent
You will be asked by JAWONIO staff to sign a consent form. This document includes consent
to the use and disclosure of your protected health information for treatment, payment and health
care operations purposes, as described in this Section 1. Your protected health information may
be used and disclosed by our staff and those outside of our agency that are involved in your care
and treatment for the purpose of providing services to you. Your protected health information
may also be used and disclosed to bill your insurance and to support the operation of JAWONIO.
Following are examples of the types of uses and disclosures of your protected health care
information that JAWONIO is permitted to make. These examples are not meant to be
exhaustive, but to describe the types of uses and disclosures that may be made by our Agency.
Treatment: We will use and disclose your protected health information to provide, coordinate,
or manage your services. This includes the coordination or management of your services with
the doctors, nurses, psychologists, social workers, program directors or other Jawonio personnel
who are involved in providing you care, or a third party that has already obtained your
permission to have access to your protected health information, such as another service provider.
For example, we might disclose your protected health information, as necessary, to your
treatment team to develop and provide you with services identified in your ISP or treatment plan.
We may also need to disclose your health/clinical information to other providers outside of
JAWONIO in order to obtain new services for you.
Payment: Your protected health information will be used, as needed, so that we can bill and
obtain payment for services from you, a third party, an insurance company, Medicare or
Medicaid or other government agencies. For example, obtaining services may require that your
relevant protected health information be disclosed to a health plan to obtain approval for
JAWONIO services. We may need to disclose your PHI for obtaining insurance benefits,
undertaking utilization review activities or making a determination of eligibility. We may also
need to provide Medicaid with information about the services you receive so that they will pay
us for the services. In addition, bills may be sent to you or third party payers, such as insurance
companies or health plans. The information on the bill may contain information that identifies
you, your diagnosis and services provided.
Healthcare Operations: We may use or disclose, as needed, your protected health
information in order to support the business activities of JAWONIO. These activities include, but
are not limited to, quality assessment activities, employee review activities, training of health
professionals and students, licensing, and conducting or arranging for other business activities.
For example, we may use your information to evaluate the performance of staff involved in your
care, to assess the quality of care you receive, and to learn how to improve our services. We may
also disclose information to clinicians and other personnel for on-the-job training.
Business Associates: We will share your protected health information with third party “business
associates” that perform various activities for JAWONIO. Whenever an arrangement between
our Agency and a business associate involves the use or disclosure of your protected health
information, we will have a written contract that contains terms that will protect the privacy of
your protected health information.
Fundraising: We may use or disclose certain information about you in order to contact you for
fundraising activities supported by JAWONIO. You have the right to opt out of receiving these
materials. If you or your family does not want to receive these materials, please contact our
Privacy Officer and request that these fundraising materials not be sent.
Uses and Disclosures of Protected Health Information Based upon Your Written
Certain uses and disclosures require your authorization. An authorization is required, with
certain exceptions, for any use or disclosure of your protected health information for marketing
purposes or for purposes involving the sale of your protected health information. Also, a
specific authorization is required for the release of HIV/AIDS, mental health, and psychotherapy
notes and information.
Except as described in this Notice, uses and disclosures will be made with your written
authorization. You may revoke such authorization, at any time, in writing, except to the extent
that JAWONIO has taken an action in reliance on the use or disclosure indicated in the
Other Permitted and Required Uses and Disclosures That May Be Made With Your
Consent, Authorization or Opportunity to Object
We may disclose to a member of your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates to that person’s involvement in
your health care. If you are unable to agree or object to such a disclosure, we may disclose such
information as necessary if we determine that it is in your best interest based on our professional
judgment. In this regard, we will ask you to provide us with the names of persons to whom we
may speak. We may use or disclose protected health information to notify or assist in notifying a
family member, personal representative or any other person that is responsible for your care of
your location, general condition or passing. Finally, we may use or disclose your protected
health information to an authorized public or private entity to assist in disaster relief efforts and
to coordinate uses and disclosures to family or other individuals involved in your health care.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your
Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without
your consent or authorization. These situations include:
Required by Law: We may use or disclose your protected health information to the extent that
the use or disclosure is required by law. The use or disclosure will be made in compliance with
the law and will be limited to the relevant requirements of the law. You will be notified, as
required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities
and purposes to a public health authority that is permitted by law to collect or receive the
information. The disclosure will be made for the purpose of controlling disease, injury or
disability. We may also disclose your protected health information, if directed by the public
health authority, to a foreign government agency that is collaborating with the public health
Communicable Diseases: We may disclose your protected health information, if authorized by
law, to a person who may have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections. Oversight
agencies seeking this information include government agencies that oversee the health care
system, government benefit programs, other government regulatory programs and civil rights
Abuse or Neglect: We may disclose your protected health information to a public health
authority that is authorized by law to receive reports of child abuse or neglect. In addition, we
may disclose your protected health information if we believe that you have been a victim of
abuse, neglect or domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a
person or company required by the Food and Drug Administration to report adverse events,
product defects or problems, biologic product deviations, tract products; to enable product
recalls; to make repairs or replacements, or to conduct post-marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial
or administrative proceeding, in response to an order of a court or administrative tribunal (to the
extent such disclosure is expressly authorized), and in certain conditions in response to a
subpoena, discovery request or other lawful process. Special rules apply for HIV/AIDS
information and mental health information.
Law Enforcement: We may also disclose protected health information, so long as applicable
legal requirements are met, for law enforcement purposes. These law enforcement purposes
include (1) legal processes and as otherwise required by law, (2) limited information requests for
identification and location purposes, (3) disclosures pertaining to victims of a crime, (4) where
there is suspicion that death has occurred as a result of criminal conduct, (5) in the event that a
crime occurs on the premises of JAWONIO and (6) medical emergency (not on JAWONIO’s
premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health
information to a coroner or medical examiner for identification purposes, determining cause of
death or for the coroner or medical examiner to perform other duties authorized by law. We may
also disclose protected health information to a funeral director, as authorized by law, in order to
permit the funeral director to carry out their duties. We may disclose such information in
reasonable anticipation of death. Protected health information may be used and disclosed for
cadaveric organ, eye or tissue donations purposes.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your
protected health information, if we believe that the use or disclosure is necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the public. We may
also disclose protected health information if it is necessary for law enforcement authorities to
identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use
or disclose protected health information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities; (2) for the purpose of
a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to
foreign military authority if you are a member of that foreign military services. We may also
disclose your protected health information to authorize federal officials for conducting national
security and intelligence activities, including for the provision of protective services to the
President or other legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us as to
comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a
correctional facility and your physician created or received your protected health information in
the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when
required by the Secretary of the Department of Health and Human Services to investigate or
determine our compliance with the requirements of Section 164.500 et. seq.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a
brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you
may inspect and obtain a copy of protected health information about you for as long as we
maintain the protected health information.
We may charge a reasonable, cost-based fee for the costs of copying, mailing or other supplies
associated with your request, up to $0.75 per page for copied records. We may deny your
request to inspect and copy in certain limited circumstances. If you are denied access, you may
request that the denial be reviewed by JAWONIO and/or the New York State Office of Mental
Health. Please contact our Privacy Officer if you have questions about access to your medical
You have the right to request a restriction of your protected health information. This
means you may ask us not to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may also request that any part of
your protected health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice of Privacy Practices.
Your request must state the specific restriction requested and to whom you want the restriction to
JAWONIO is not required to agree to a restriction that you may request, except we must agree to
your request to restrict the information we provide to your health plan if the disclosure is not
required by law and the information relates to health care being paid in full by someone other
than the health plan. If JAWONIO believes it is in your best interest to permit use and disclosure
of your protected health information, your protected health information will not be restricted. If
JAWONIO does agree to the requested restriction, we may not use or disclose your protected
health information in violation of that restriction unless it is needed to provide emergency
treatment. You may request a restriction by contacting our Privacy Officer in writing.
You have the right to request to receive confidential communications from us by
alternative means or at an alternative location. We will accommodate reasonable requests.
We may also condition this accommodation by asking you for information as to how payment
will be handled or specification of an alternative address or other method of contact. We will not
request an explanation from you as to the basis for the request. Please make this request in
writing to our Privacy Officer.
You may have the right to have JAWONIO amend your protected health information.
This means you may request an amendment of protected health information about you in a
designated record set for as long as we maintain this information. In certain cases, we may deny
your request for an amendment. If we deny your request for amendment, you have the right to
file a statement of disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if
you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of
your protected health information. This right applies to disclosures for purposes other than
treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It
excludes disclosures we may have made to you, for a facility directory, to family members or
friends involved in your care, pursuant to your request, or for notification purposes.
You have the right to obtain a paper copy of this Notice from us, upon request, even if you
have agreed to accept this Notice electronically.
Other Uses of Health Information: Certain releases of health information may be made only
with your written permission. If you provide us permission to use or disclose health information
about you, you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose health information about you for the reasons
covered by your written authorization.
You may complain to us or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated by contacting the Office for Civil Rights,
U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza
– Suite 3312, New York, NY 10278; Phone (800) 368-1019.
You may contact JAWONIO’S Corporate Compliance and HIPAA Hotline at 845-639-3527.
You may also contact our Privacy Officer, Carol Camenisch Simpson, at 260 North Little Tor
Road, New City, NY or by calling 845-708-2000 x 1481 for further information about the
complaint process or to file a complaint.
We will not retaliate against you for filing a complaint.
This Notice was published and becomes effective on 9/1/13.