EPC Associates,
Inc.
Benefit
Administrators
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.
At EPC Associates, Inc. we
respect your privacy and will protect your health information responsibly and
professionally. We’re required to
maintain the privacy of your health information and to provide you with this
notice. Also, we’re required to
abide by the terms of the notice that’s currently in
effect.
This notice applies to all
members of Russell Sage Foundation.
It describes how we may collect, use and disclose your health
information. It also describes your
rights concerning your health.
As you read this notice
you’ll see an important term: “protected
health information” or PHI.
PHI is information about you, including health and demographic
information created and received by us that can reasonably be used to identify
you. PHI includes information that relates to your past, present and future
physical or mental condition, the provision of health care and payment for that
care.
There are state and federal laws that may require or allow us to release your PHI to others. We may be required to provide information for the following reasons:
Health
Oversight Activities:
We may disclose your PHI to
a government agency authorized to oversee the health care system or government
programs, or its contractors.
Legal
Proceedings: We may disclose your PHI in response to
a court or administrative order, subpoena, discovery request or other lawful
process, under certain circumstances.
Law
Enforcement:
We may disclose your PHI to
law enforcement officials under limited circumstances. For example, in response to a warrant or
subpoena, or for the purpose of identifying or locating a suspect, witness or
missing person, or to provide information concerning victims of
crimes.
For
Public Health Activities:
We may disclose your PHI to
a government agency that oversees the health care system or government programs
for such activities as preventing or controlling disease or activities relating
to the quality, safety or effectiveness of an FDA regulated product or
activity.
Required
By Law: We may disclose
your PHI when required to do so by law.
Workers’
Compensation:
We may disclose your PHI
when required by Workers’ Compensation laws.
Victims
of Abuse, Neglect or Domestic Violence:
We may disclose your PHI to
appropriate authorities if we reasonably believe that you are a possible victim
of abuse, neglect, domestic violence or other crimes.
Coroners,
Funeral Directors and Organ Donation: In certain instances we may disclose
your PHI to coroners or funeral directors and in connection with organ
donations.
Research: We may disclose your PHI to
researchers if certain established steps are taken to protect your
privacy.
Threat to
Health or Safety: We may disclose your PHI to the extent
necessary to avert a serious and imminent threat to your health or safety or the
health or safety of others.
Specialized
Government Functions:
We may disclose your PHI in
certain circumstances or situations to a correctional institution if you are an
inmate in a correctional facility, to an authorized federal official when it’s
required for lawful intelligence or other national security activities, or to an
authorized authority of the Armed Forces.
Before we can use or
disclose your PHI for any reason other than those listed above, we are required
to obtain your written authorization./
You may revoke the authorization at any time as long as you do so in
writing. Information provided as a
result of your authorization will no longer be provided once you revoke the
authorization.
You have the right to ask us
to restrict our use and disclosure of protected health information for the
purposes of treatment, payment or health care operations. This includes uses and disclosures to
family members, relatives, close personal friends or other persons identified by
you who may be involved with your care or payment for your care. We will consider your request but we are
not required to agree to restrict the information.
You have the right to ask to
receive confidential communications.
You may request that when we send communications to you that contain PHI,
we send them to you be alternative means or to an alternative location. You must request this in writing and
clearly state that our disclosure of all or part of that communication could
endanger you. You must also tell us
the alternative location (e.g. fax number, address, etc) to which you would like
us to send the information.
You have the right to
inspect and obtain a copy of the PHI that we maintain about you in a designated
record set. A designated record set
contains PHI that we collect, maintain or use to administer or make decisions
regarding your enrollment, payment, claims adjudication or case/medical
management. Requests to access the information must be made
in writing and we will respond in 30 days of receipt of your
request.
You have the right to ask us
to amend PHI about you. All
amendment requests must be made in writing and include a reason for the
request. We will respond within 60
days of receiving the request. If
the request is approved we will amend the information contained in our
records. In certain cases the
request may be denied. For example
we may deny a request if the information we have on file is accurate or if we
didn’t create the information. We
will notify you in writing of any denial.
You may respond by filing a written statement of disagreement with us and
we have the right to rebut the disagreement statement. Should this occur, you have the right to
request that your original request, our denial and any statement of
disagreement, along with our rebuttal be included in future disclosures of the
PHI.
You have the right to
request an accounting of certain disclosures of PHI. An accounting will show you to whom we
provided your PHI. The first
accounting in a 12 month period of time will be provided free of charge. Subsequent requests are subject to a
reasonable, cost-based fee of which you will be made aware of in
advance.
Complaints
and Inquiries
You may register a complaint with us or to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with us, please submit it in writing and address it to:
Joan
Clifford
Compliance
Officer
EPC Associates,
Inc.
85 W. Main
Street
Bay Shore NY
11706
631-666-2616
To submit a complaint to the Secretary of the Department of Health and Human Services, please submit it in writing to:
Secretary, Department of
Health and Human Services
206 Independence Avenue
SW
Washington DC
20201
877-696-6775
Your complaint should include the following:
Please Note: You will not be retaliated against or denied any health plan benefit or service because you file a complaint.