Youngerman Center for Communication Disorders
Department of Communication Disorders and Sciences
I. 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.
We are legally required to protect the privacy of health information that may reveal
your identity. This information is commonly referred to as "protected health information,"
or "PHI" for short. It includes information that can be used to identify you that
we have created or received about your past, present or future health or condition,
the provision of health care to you, or the payment of this health care. We must provide
you with this notice about our privacy practices that explains how, when and why we
use and disclose your PHI. We reserve the right to change the terms of this notice
and our privacy policies at any time. Any changes will apply to the to the PHI we
already have. Before we make an important change to our policies, we will promptly
change this notice and post a new notice. A copy of our current notice will always
be posted in the reception area. You will also be able to obtain your own copies by
accessing our website at www.fredonia.edu, calling our office at (716) 673-3203 or
asking for one at the time of your next visit.
With some exceptions, we may not use or disclose any more of your PHI than is necessary
to accomplish the purpose of the use or disclosure. We are legally required to follow
the privacy practices that are described in this notice.
II. When we may use and disclose your health information with your consent
During your intake, prior to receiving any heath care services you will be asked to
sign a one-time consent permitting the Youngerman Center's employees and student trainees
to use and disclose your health information for the purposes of treatment, payment,
and health care operations. We are allowed by law to refuse to treat you if you do
not sign the consent form. A description of each of these uses is described as follows:
A. Treatment, Payment and Youngerman Center Operating Practices
- For Treatment: We share and use your PHI with clinical staff supervisors and student practitioners
at the Youngerman Center who are involved in diagnosing and treating you. We may disclose
your PHI to physicians, allied health care personnel, school personnel who have referred
you to the Youngerman Center and are involved in your care and to coordinate your
care. We may disclose your PHI to another health care provider to whom you have been
referred for further care. We may disclose your PHI to manufacturers when we order
a hearing aid for you. Sometimes we may ask for copies of your health information
from another professional that you may have seen before us to diagnosis or treat you.
PHI may be exchanged via the mail or by fax.
- For Payment: We may use and disclose your PHI in order to bill and collect payment for the treatment
and services provided to you. For example, we may provide portions of your PHI to
our billing staff and your health plan to get paid for the health care services we
provided to you. We may also provide your PHI to a business associate, such as a billing
company or claims processing company that process our health care claims or provide
services on our behalf. We use your PHI for payment purposes when, for example, our
staff asks you about health insurance or about other sources of payment for our services,
when we prepare bills to send to you or your health plan, when we process payment
by credit card and when we try to collect unpaid amounts due. We may disclose your
PHI outside of our office for payment purposes when, for example, bills or claims
for payment are mailed or faxed to you or your health insurance, or when we occasionally
have to ask a collection agency to help us with unpaid amounts due.
- For Operating Practices: The Youngerman Center is a part of a professional training program at SUNY Fredonia
and includes student trainees and student observers. Student trainees have access
to your PHI as they participate in the provision of evaluation and treatment services
under the supervision of licensed clinical supervisors. The observation procedure
de-identifies your PHI to student observers. Video or audiotapes of sessions may be
recorded for confidential use. Such uses are: to analyze diagnostic test results,
to rate your progress in treatment, to evaluate the student's clinical skills, or
to demonstrate evaluation and treatment strategies for teaching purposes.
We may use and disclose your PHI to send you a mailing with information about our
practice or a new product. For example, your name and address may be used to send
you a newsletter about our practice and the services we offer or to update you on
a new type of hearing aid available.
We may disclose your PHI to business associates that provide a service for the Youngerman
Center, i.e., a computer software vendor who installs and upgrades our billing program,
an accreditation agency that audits our academic and clinical program. To the extent
we are required to disclose your PHI to contractors, agents or other business associates,
we will have a written contract to ensure that our business associate also protects
the privacy of your PHI.
We may use your PHI when we contact you with a reminder that you have an appointment
for a service at the Youngerman Center or to inform you that your hearing aid is available
for pick-up. We will phone you at a number that you have provided, speak with the
person who answers and leave a message or leave the message on an answering machine.
B. Other USE And Disclosures That Do Not Require Your Consent.
We may use and disclose your PHI without your consent or authorization for the following
- When a disclosure is required by federal, state, or local law, judicial or administrative
proceedings or law enforcement. For example, we make disclosures when a law requires that we report information to
government agencies and law enforcement personnel about victims of abuse, neglect
or domestic violence or when ordered in a judicial or administrative proceeding.
- For health oversight activities. For example, we will provide information to assist the government when it conducts
an investigation or inspection of a health care provider or organization.
- Lawsuits and Disputes. We may disclose your PHI if we are ordered to do so by a court or administrative
tribunal that is handling a lawsuit or other dispute.
- Law Enforcement. We may disclose your PHI to law enforcement officials for any of the following reasons:
- To comply with court orders or laws that we are required to follow;
- To assist law enforcement officers with identifying or locating a suspect, fugitive,
witness or missing person;
- If you have been the victim of a crime and we determine that: (1) we have been unable
to obtain your consent because of any emergency or your incapacity; (2) law enforcement
officials need the information immediately to carry out their law enforcement duties;
and (3) in our professional judgement disclosure to these officers is in your best
- If we suspect a patient's death resulted from criminal conduct;
- If necessary to report a crime that occurred on our property; or
- If necessary to report a crime discovered during an off-site medical emergency (for
example, by emergency medical technicians at the scene of a crime).
- Military and Veterans. If you are in the Armed Forces, we may disclose your PHI to appropriate military
command authorities for activities they deem necessary to carry out their military
mission. We may also release health information about foreign military personnel to
the appropriate foreign military authority.
- Abuse or Neglect. We may release your PHI to a public health authority that is authorized to receive
reports of abuse, neglect or domestic violence. For example, we may report your information
to government officials if we reasonably believe that you have been a victim of abuse,
neglect or domestic violence. We will make every effort to obtain your permission
before releasing this information, but in some cases we may be required or authorized
to act without your permission.
- Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose
your PHI to the prison officers or law enforcement officers if necessary to provide
you with health care, or to maintain safety, security and good order at the place
where you are confined. This includes sharing information that is necessary to protect
the health and safety of other inmates or persons involved in supervising or transporting
- For research purposes. In most cases, we will ask for your written authorization before using your PHI for
research purposes. However, in certain, limited, circumstances, we may use and disclose
your PHI without consent or authorization if we obtain approval through a special
process to ensure that such research poses little risk to your privacy. In any case,
we would never allow researchers to use or name or identity publicly. We may also
release your health information without your written authorization to people who are
preparing for a future research project, so long as no personally identifiable information
leave our facility.
- For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. We
may disclose PHI for national security purposes, such as protecting the President
of the United States or conducting intelligence operations.
- For workers' compensation purposes. We may provide PHI in order to comply with workers' compensation laws.
- Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment
alternatives or other health care services or benefits we offer and/or provide.
- De-identified Information. We may also disclosure your PHI if it has been de-identified or unable for anyone
to connect back to you. This might occur if you are participating in a research project.
- Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your PHI, certain
disclosures of your PHI may occur during, or as an unavailable result of our otherwise
permissible uses or disclosures of your health information. For example, during the
course of a treatment session, other patients in the treatment area may see or overhear
discussion of your PHI.
C. One Use and Disclosure Requires You to Have the Opportunity to Object.
- Disclosures to family, friends or others. We may provide your PHI to a family member, friend or other person who you indicate
is involved in your care or the payment for your health care, unless you object in
whole or part. The opportunity to consent may be obtained retroactively in emergency
D. All Other Uses and Disclosures Require Your Prior Written Authorization.
In any other situation not described in section II A, B and C above, we will ask for
your written authorization before using or disclosing any of your PHI. If you choose
to sign an authorization to disclose your PHI, you can later revoke that authorization
in writing to stop any future uses and disclosures (to the extent that we have not
taken any actions relying on the authorization).
III.WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect to your PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will
consider your request, but are not legally required to accept it. If we accept your
request, we will put any limits in writing and abide by them except in emergency situations.
You may not limit the uses and disclosures that we are legally required or allowed
- The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you to an alternate address
or by alternate means. We must agree to your request so long as we can easily provide
it to the location and in the format you request.
- The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or obtain copies of your PHI that we
have, but you must make the request in writing. If we don't have your PHI but we know
who does, we will tell you how to get it. We will respond to you within 30 days after
receiving your written request. In certain situations, we may deny your request. If
we do, we will tell you, in writing, our reasons for the denial and explain your right
to have the denial reviewed. If you request copies of your PHI, we will charge you
a fee for each page. Instead of providing the PHI you requested, we may provide you
with a summary or explanation of the PHI as long as you agree to that and to the associated
cost in advance.
- The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your PHI.
The list will not include uses or disclosures that you have already been informed
of, such as those made for treatment, payment or health care operations, directly
to you, to your family, or in our facility directory. The list also won't include
uses and disclosures made for national security purposes, to corrections or law enforcement
personnel or before April 14, 2003.
Your request must state a time period for the disclosures you want us to include.
We will respond Within 60 days of receiving your request. The list we will give you
will include disclosures made in the last six years (with the oldest date being April
14, 2003) unless you request a shorter time. The list will include the date of the
disclosure, to whom PHI was disclosed (including their address, if known), a description
of the information disclosed and the reason for the disclosure. We will provide the
list to you at no charge, but if you make more than one request in the same calendar
year, we will charge you for each additional request.
- The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information
is missing, you have the right to request that we correct the existing information
or add the missing information. You must provide the request and your reason for the
request in writing. We will respond within 60 days of receiving your request. We may
deny your request in writing if the PHI is (i) correct and complete, (ii) not created
by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written
denial will state the reasons for the denial and explain your right to file a written
statement of disagreement with the denial. If you don't file one, you have the right
to request that your request and our denial be attached to all future disclosures
of your PHI.
If we approve your request, we will make the change to your PHI, tell you that we
have done it and tell others who need to know about the change to your PHI.
- The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed
to receive notice via e-mail, you also have the right to request a paper copy of this
IV. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES.
If you think we may have violated your privacy rights, or you disagree with a decision
we made about access to your PHI, you may file a complaint with the person listed
in Section V below. You also may send a written complaint to the Secretary of the
Department of Health and Human Services at:
US Department of HHS Government Center
John F. Kennedy Federal Building- Room 1875
Boston, Massachusetts 02203
Telephone number: 617-565-1340
Fax number: 617-565-3809
We will take no retaliatory action against you if you file a complaint about our privacy
V. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY
If you have any questions about this notice. or any complaints about our privacy practices,
or would like to know how to file a complaint with the Secretary of the Department
of Health and Human Services, please contact us via e-mail at email@example.com or
Julie Williams, Privacy Officer
SUNY at Fredonia
Fredonia, NY 14063
VI. EFFECTIVE DATE OF THIS NOTICE
This notice is effective as of April 14, 2003
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing below, I acknowledge that I have been provided a copy of this Notice of
Privacy Practices and have therefore been advised of how certain health information
about me may be used and disclosed by health care facilities and operations of the
State University of New York, and how I may obtain access to and control this information.
I also acknowledge and understand that I may request copies of separate notices explaining
special privacy protections that apply to HIV-related information, alcohol and substance
abuse treatment information, mental health information and genetic information.
Signature of Patient or Personal Representative
Print Name of Patient or Personal Representative
Description of Personal Representative's Authority
Notice of Privacy Practices Version Number
Notice of Privacy Practices Date