Enrique Ergas, M.D. P.C.
1056 Fifth Avenue
New York, N.Y. 10028

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.

I. Who Are We
This Notice describes the privacy practices of Enrique Ergas, M.D., P.C.

II. Our Privacy Obligations
We are required by law to maintain the privacy of medical and health information about you (“Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Uses and Disclosures With Your Consent or Your Authorization

A. Uses and Disclosures With Your Consent. Except in an emergency or other special circumstance, before providing treatment to you, we will ask you to read and sign a written consent to our use and disclosure of Protected Health Information for purposes of treatment provided to you, obtaining payment for services provided to you and for our health care operations (e.g., internal administration, quality improvement and customer service) (“Your Consent”) as detailed below:

Treatment. We use and disclose Protected Health Information to provide treatment and other services to you- for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose Protected Health Information to other providers involved in your treatment.

Payment. We may use and disclose Protected Health Information to obtain payment for services that we provide to you- for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”), or to verify that Your Payor will pay for health care.

Health care Operations. We may use and disclose Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose Protected Health Information to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

B. Use or Disclosure with Your Authorization. As described above, Your Consent only permits us to use Protected Health Information for purposes of treatment, payment and our health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment and health care operation only when (1) you give us your authorization on our authorization form (“Your Authorization”) or (2) there is an exception described in Section IV below. Further, you may revoke Your Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Office Manager identified below. [Implementation guideline: a provider that maintains psychotherapy notes may wish to state that the individual’s authorization is necessary to use psychotherapy notes for treatment, payment and health care operations under certain circumstances under 164.508 (a)(2).] [Implementation guideline: the authorization form needs to comply with more stringent state laws. In particular, consider state laws regulating use and disclosure of disease/illness-specific health information, such as HIV/AIDS.]

C. Special Authorization. Confidential HIV related information (for example, information regarding whether you have ever been the subject of an HIV test, have HIV infection, HIV related illness or AIDS, or any information which could indicate that you have ever been potentially exposed to HIV) will never be used or disclosed to any person without your specific written authorization, except to certain other persons who need to know such information in connection with your medical care, and, in certain limited circumstances, to public health or other government officials (as required by law), to persons specified in a special court order, to insurers as necessary for payment for your care or treatment, or to certain persons with whom you have had sexual contact or have shared needles or syringes (in accordance with a specified process set forth in New York State law). This special written authorization (“Your Special Authorization”) is a New York State approval form which is a separate document from Your Consent and Your Authorization.

There are only certain types of disclosures of confidential HIV related information which are permitted with Your Consent or Your Authorization, respectively, as opposed to Your Special Authorization.

Your Consent is all that is necessary for:
Disclosures to a third party to the extent necessary to receive payment for health care services rendered to you;
Disclosures to accreditation/oversight review committees, government agencies or the Practice’s internal committees, in accordance with New York State law, in order to carry our the monitoring, evaluation, supervision or regulation of the Practice;
Disclosures to individuals within the Practice who are authorized to access your medical records, provide health care to you, or maintain/process your medical records for billing or reimbursement;
Disclosures to health care professionals and institutions outside the Practice when necessary for your treatment; and
Disclosures to health care professionals or institutions in relation to the procurement or use of a human body part or fluids for use in medical education, research, therapy or for transplantation to individuals.

Your Authorization is all that is necessary for
Disclosures to a third party payor for any reason other than obtaining payment for health care services rendered to you.

IV. Uses and Disclosures Without Your Consent or Your Authorization

A. Use or Disclosure For Treatment. Payment and Health Care Operations Without Your Consent or Your Authorization. We may use or disclose Protected Health Information for purposes of treatment, obtaining payment and our health care operations without Your Consent or Your Authorization under the following three circumstances: (1) when you require emergency treatment; (2) when we are required by law to treat you and we attempt to obtain Your Consent, but are unable to obtain it; and (3) when we attempt to obtain Your Consent but are unable to obtain it due to substantial barriers to communicating with you (e.g. you are unconscious or otherwise incapacitated) and you would have consented in the absence of the barriers.

B. Disclosure to Relatives and Close Friends. We may use or disclose Protected Health Information to a family member, other relative, a close friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interest. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care.

C. Marketing Communications. We may use or disclose Protected Health Information to identify health-related services and products that may be beneficial to your health and then contact you about the service and products. If you do not want to receive these marketing communications in the future, you may contact our Office manager at 212-248-3636.

D. Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

E. Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.

F. Judicial and Administrative Proceedings. We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

G. Law Enforcement Officials. We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

H. Decedents. We may disclose Protected Health Information to a coroner or medical examiner as authorized by law.

I. Organ and Tissue Procurement. We may disclose Protected Health Information to organizations that facilitate organ, eye or tissue procurement banking or transplantation.

J. Research. We may use or disclose Protected Health Information without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.

K. Health or Safety. We may use or disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

L. Specialized Government Functions. We may use and disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances required by law.

M. Workers’ Compensation. We may disclose Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

V. Your Individual Rights

A. For Further Information: Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to Protected Health Information, you may contact our Office Manager. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Office Manager will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified to you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. All requests for such a restriction must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Office Manager and submit the completed form to the Office Manager. We will send you a written response.

C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, please obtain a record request form from the Office Manager and submit the completed form to the Office Manager. If you request copies, we will charge you [$0.75 (seventy five cents)] for each page.

You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records relating to venereal disease, abortion, or care and treatment to which the minor is permitted to consent himself/herself (without your consent) such as HIV testing, sexually transmitted disease diagnosis and treatment, chemical dependence treatment, prenatal care, care received by a married minor, and contraception and/or family planning services).

E. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Office Manager and submit the completed form to the Office Manager. All requests for amendments must be in writing. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

F. Right to Receive An Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you [$.___ per page] of the accounting statement.

G. Right to Receive Paper Copy of this Notice. Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on April 14, 2003.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice term effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in waiting areas of the Practice [and on our Internet site at www.ergasmd.com. You may also obtain any revised notice by contacting the Office Manager.

VII. Office Manager
You may contact the Office Manager at:
Author Dash
1056 Fifth Avenue
New York, N.Y. 10028

Enrique Ergas M.D., P.C.
1056 Fifth Avenue
New York, N.Y. 10028
Telephone Number: 212-348-3636
Fax Number: 212-410-3338
Email Address: eemdpc@aol.com

[NPRM requires changes to the Notice consistent with other changes to the Privacy Rule]