FRANK DOLISI, M.D.
394 OLD COUNTRY ROAD
GARDEN CITY, N.Y. 11530
(516) 742-2224
FAX# (516) 742-7470

EFFECTIVE APRIL 14, 2003

HEALTH INFORMATION PRIVACY ACT (HIPPA) NOTICE

THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US. YOU MAY BE AWARE THAT THE U.S. GOVERNMENT REGULATORS ESTABLISHED A PRIVACY RULE (HIPPA) GOVERNING PROTECTED HEALTH INFORMATION (PHI). THIS NOTICE TELLS YOU ABOUT HOW IT MAY BE USED, AND ABOUT CERTAIN RIGHTS YOU HAVE.


WE HAVE A DESIGNATED PRIVACY CONTACT PERSON HANDLING ALL PRIVACY MATTERS IN OUR OFFICE. YOU CAN CONTACT HER AT THIS OFFICE IF YOU DESIRE FURTHER INFORMATION, OR HAVE ANY QUESTIONS OR CONCERNS. ADDITIONALLY A MORE DETAILED NOTICE OF OUR PRIVACY NOTICE IS AVAILABLE TO YOU BOTH IN THE RECEPTION AREA AND FROM OUR FRONT DESK STAFF.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:

FEDERAL LAW PROVIDED THAT WE MAY USE YOU PROTECTED HEALTH INFORMATION (PHI) FOR TREATMENT OF YOU, WITHOUT FURTHER SPECIFIC NOTICE TO YOU, OR WRITTEN AUTHORIZTIN BY YOU. FOR EXAMPLE, WE ARE REQUIRED BY HEALTH INSURANCE PLANS TO PROVIDE THEM WITH A DIAGNOSIS CODE FOR YOUR VISIT, AND A DESCRIPTION OF SERVICES RENDERED.

FEDERAL LAW PROVIDE THAT WE MAY USE YOU MEDICAL INFORMATION FOR OFFICE PURPOSES WITHOUT FURTHER SPECIFIC NOTICE TO YOU, OR WRITTEN INFORMATION BY YOU. FOR EXAMPLE OUR ACCOUNTANTS MAY SEE YOUR NAME, DATES OF TREATMETN AND PROCEDURE CODES DURING AUDIT OF OUR BOOKS.

WE MAY USE OR DISCLOSE YOU MEDICAL INFORMATION, WITHOUT FURTHER NOTICE TO YOU, OR SPECIFIC AUTHORIZATION BY YOU WHERE:
1. REQUIRED BY LAW.
2. REQUIRED FOR PUBLIC HEALTH PURPOSES.
3. REQUIRED BY LAW TO REPORT A CHIL OR ELDER ABUSE.
4. WHERE REQUIRED BY A HEALTH OVERSIGHT AGENCY FOR OVERSIGHT ACTIVITIES AUTHORIZED BY LAW, SUCH AS THE DEPARTMENT OF HEALTH, OFFICE OF PROFESSIONAL CONDUCT.
5. REQUIRED BY LAW IN A JUDICAL OR ADMINISTRATIVE PROCEEDINGS.
6. REQUIRED FOR LAW ENFORCEMANT PURPOSES.
7. REQUIRED BY A CORONER OR MEDICAL EXAMINER.
8. PERMITTED BY LAW TO A FUNERAL DIRECTOR.
9. PERMITTED BY LAW FOR ORGAN DONATION PURPOSES.
10. PERMITTED BY LAW TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY.
11. PERMITTED BY LAW AND REQUIRED BY MILITARY AUTHORITIES IF YOU ARE A MEMBER OF THE ARMED FORCES OF THE U.S.

NEW YORK STATE LAW PROVIDES ADDITIOANL PROTECTION FOR INFORMATION REGARDING HIV/AIDS. WE WILL CONTINUE TO FOLLOW NEW YORK STATE LAW WITH RESPECT TO SUCH INFORMATION.

WE MAY CONTACT YOU BY MAIL OR PHONE AT YOUR RESIDENCE, TO PROVIDE INFORMATION ABOUT YOUR TREATMENT. UNLESS YOU INSTRUCT US OTHERWISE, WE MAY LEAVE A MESSAGE FOR YOU ON ANY ANSWERING DEVICE OR WITH ANY PERSON WHO ANSWERS THE PHONE AT YOU RESIDENCE.

OTHER USES OR DISCLOSURES OF MEDICAL INFORMATION WILL BE MADE ONLY WITH YOUR WRITTEN AUTHORIZATION. FOR EXAMPLE, YOU WILL NEED TO EXECUTE AN AUTHORIZATION FORM BEFORE WE CAN SEND YOUR PHI (PROTECTED HEALTH INFORMATION) TO A LIFE INSURANCE.

WE PREFER TO HAVE YOU PICK UP COPIES OF YOUR PHI IN SUCH INSTANCES, SINCE FAX MACHINES ARE NOT AN ABSOLUTELY "SECURE/PRIVATE" MEANS TO TRANSMIT YOU PHI.

IF YOU WISH TO COMPLAIN ABOUT VIOLATIONS OF YOUR PRIVACY RIGHTS, YOU HAVE A RIGHT TO FILE A COMPLAINT WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OF THE UNITED STATES. YOU MAY ALSO FILE A COMPLAINT WITH US BY CONTACTING OUR OFFICE AND ASKING TO SPEAK TO THE PRIVACY CONTACT AT (516) 742-2224.

NO RETALIATORY ACTION WILL BE TAKEN AGAINST YOU FOR ANY COMPLAINT YOU MAY MAKE.

WE REQUEST THAT YOU SIGN A SATEMENT THAT YOU HAVE RECEIVED A PAPER COPY OF THIS NOTICE FOR YOUR RECORDS. IT IS FEDERAL LAW THAT THIS SIGNED STATEMENT BE KEPT IN YOUR MEDICAL CHART.