HIPPA

FORESTDALE, INC

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW CONFIDENTIAL INFORMATION MAY BE USED AND DISCLOSED AND HOW THIS INFORMATION MAY BE ACCESSED.

PLEASE REVIEW IT CAREFULLY.

In order to provide high-quality Foster Care services, FORESTDALE, INC collects, creates and maintains information about our families. We are required by law to maintain the privacy of this information. This Notice of Privacy Practices describes how we use and disclose confidential information, and explains certain rights you may have regarding this information. We are required by Federal law to provide this Notice and we will comply with its terms during the period when it is in effect.

Federal law requires that we protect the privacy of children in foster care. We generally give this Notice to the child if he or she has the capacity under the law to make health care decisions or, if not, to the child’s parent or legal guardian.

Section I
What Information We Protect

We protect any information that identifies the child or could be used to identify the child. This includes the child’s name, address and other basic identifying information used in the course of providing Foster Care services to the child. This information is protected even if unaccompanied by information about your health, treatment or benefits.

Section II
How We Use and Disclose Your Health Information

The following is a list of the ways that we may use and disclose the child’s health information. We will use and disclose the child’s health information only for one of the reasons on this list. In certain cases we provide examples of the types of uses or disclosures that fall within a particular category. These examples are intended to help you understand what these categories mean; they do not cover every type of use or disclosure within each category. In addition, more restrictive rules may apply to certain types of sensitive health information such as HIV/AIDS records.

  1. Treatment, Payment and Health Care Operations. We may use and disclose the child’s confidential information without written authorization to carry out treatment, payment and health care operations.
    1. Treatment. We may use and disclose the child’s health information to treat the child or to assist other health care providers from whom the child is receiving health care services. For example, if the child is admitted to a hospital, we may provide the hospital with information about the services we have provided to the child to assist the hospital in delivering appropriate care.
    2. Payment. We may use and disclose the child’s confidential information to obtain payment for our services or to assist other health care providers with their payment activities. For example, we may submit claims for reimbursement to the Medicaid program.
    3. Health Care Operations. We may use and disclose confidential health information about the child to carry out general business and health care operations. These operations include quality improvement activities, evaluating the performance of our health care practitioners and resolving any complaints or grievances.
  2. Family Members or Friends.
    1. Family Members. We may share information about the child with family members in obtaining treatment or benefits for the child.
  3. Public Interest Purposes. We may use and disclose the child’s confidential information without written consent or authorization for certain public interest purposes permitted or required by law, including but not limited to:
    1. Where required by state, federal or local law;
    2. For public health activities;
    3. About victims of abuse, neglect or domestic violence;
    4. In response to an appropriate order of a court or administrative body;
    5. For law enforcement purposes;
    6. About deceased individuals.
    7. To avert a serious threat to health or safety. We may use or disclose confidential information to prevent or lessen a serious and immediate threat to the health or safety of any person or the general public. We will disclose information for this purpose only to someone who may be able to prevent or lessen this type of threat.
  4. Obtaining Your Authorization for Other Uses and Disclosures. FORESTDALE, INC will not use or disclose health information for any Purpose not specified in this Notice without written authorization. The written authorization we obtain, unlike a general consent, will specifically describe the particular purpose of the use or disclosure, the information being used or disclosed and the person or entity receiving the information.
  5. Special Rules for Sensitive Health Information. The following kinds of information are subject to special privacy safeguards:
    1. HIV-Related Information;
    2. Alcohol and Substance Abuse Treatment Records;
    3. Information Related to Preventive Services.

For more information regarding these specific safeguards, you may make an appointment with the Privacy Officer at Forestdale, Inc.

Section III
Who May Exercise Your Rights

Any Foster Care child who has the capacity to make health care decisions on his or her own behalf under the law, may exercise his or her rights under this Notice; otherwise, in certain circumstances, a parent or legal guardian may exercise those rights.

Section IV
Your Rights Regarding Your Health Information

The term “you” or “your” in Section IV of this Notice means the child to whom we are providing services.

You have the following rights regarding your health information:

  1. Right to Inspect and Copy.

    You have the right to inspect or request a copy of health information we maintain about you, such as medical or billing records. Your request should describe the information you want to review and the format in which you want to review it; for example, whether you want to inspect your records at our offices, receive paper copies or get the information on a computer diskette. We may refuse to allow inspection or copying of this information in certain cases. We may also charge you a reasonable fee for copying to cover our costs.

    While, as indicated above, if the child does not have the capacity to make his or her own health care decisions, a parent or guardian may exercise the rights described in this Notice, under New York law, a parent or legal guardian must generally obtain a court order to gain access to foster care records.

  2. Right to Request Amendments.

    You have the right to request changes to any health information we maintain about you if you state a reason why this information is incorrect or incomplete. We do not have to agree to make the changes you request. If we do not believe the changes you requested are appropriate, we will notify you in writing how you can have your objection to our decision included in our records.

  3. Right to an Accounting of Disclosures.

    You have the right to receive an Accounting of certain disclosures of your health information made by Forestdale, Inc. The list will only include those instances where an authorization would have been required to permit the disclosure. This Accounting will not include disclosures made for treatment, payment or health care operations or those made in the course of legal proceedings. Your request should specify the time period for which you want this list, which can be no longer than six years and may not include dates prior to April 14, 2003. The first time you ask for a list of disclosures in any 12-month period, we will provide it for free. If you request additional lists during a 12-month period, we may charge you a fee.

  4. Right to Request Restrictions.

    You have the right to request restrictions on the ways in which we use and disclose your health information for certain purposes. We do not have to agree to the restrictions you request.

  5. Right to Request Confidential Communications.

    You have the right to ask us to send health information to you in a different way or at a different location if you believe that will provide you with additional privacy protection. For example, you may ask us to send mail to an address other than your home address. You should state in your request if you believe you will be endangered by our ordinary form of communication but you do not have to explain why you believe this is the case. Your request should also specify where and/or how we should contact you. We will respect all reasonable requests.

  6. Right to Paper Copy of Notice.

    You have the right to receive a paper copy of this Notice at any time. You may receive a paper copy even if you have previously requested to receive this Notice electronically.

  7. Complaints.

    If you believe your privacy rights have been violated, you may file a complaint with FORESTDALE, INC or the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us by writing to: Privacy Officer, Forestdale, Inc., 67-35 112th Street, Forest Hills, NY, 11375. You will not be penalized or retaliated against by FORESTDALE, INC for filing a complaint.

You may exercise any of the rights specified in paragraphs 1 through 7 above by writing to: Privacy Officer, Forestdale, Inc., 67-35 112th Street, Forest Hills, NY, 11375.

Section V
Changes to this Notice

We may change the terms of this Notice of Privacy Practices at any time. If we change the terms of this Notice, the new terms will apply to all health information, whether created or received by us before or after the date on which the Notice is changed. We will provide you with a copy of the revised notice upon request and we will post it in our offices and facilities.

Additional Information

If you have any questions or would like additional information about this Notice or FORESTDALE, INC's privacy practices, please contact Privacy Officer, Forestdale, Inc., 67-35 112th Street, Forest Hills, NY, 11375.

Effective Date

This Notice of Privacy Practices is effective as of April 14, 2003.