Notice of Privacy Practices

FAMILY CHOICE OF NEW YORK, LLC

Notice of Privacy Practices

3332 Walden Ave., Suite 110, Depew, NY 14043

John Walker, 716-668-7051

Effective Date: February 1, 2010

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.

FAMILY CHOICE OF NEW YORK, LLC (“FCNY”) understands the importance of maintaining the confidentiality of your medical and personal information and is committed to maintaining the confidentiality of such information. In our provision of services for you and your health plan, we create and obtain various records concerning your medical condition, the care and treatment provided on your behalf and your payment for medical services. We use these records to ensure you receive the best possible medical care, to obtain payment for services provided for you and to enable us to meet our professional and legal obligations. FCNY is required by law to maintain the privacy of your personal information and to provide you with this notice of our legal duties and privacy practices with respect to such information. If you have any questions about this notice, please contact the Privacy Official identified above.

A. Use and Disclosure of Your Health Information

In its provision of services, FCNY obtains health information about you and stores it in paper form and on computers. This compilation of information is commonly referred to as your medical record. The information contained in your medical record includes information that enables us to identify and contact you (for example, your name, address, phone number, etc.), information about your medical condition and the treatment of your medical condition and information about sources of payment for your medical care, among other things. The medical record is the property of FCNY and/or your health care provider, but the information in the medical record belongs to you. The law permits FCNY to use and disclose the information in your medical record for the following purposes:

1. Treatment. FCNY uses information about you to provide medical care for you. FCNY discloses your medical information to its employees and others who are involved in providing the care you need. For example, we may share your medical information with physicians and other health care providers who provide services FCNY does not provide. We also may disclose your medical information to your family, close personal friends and personal representatives.

2. Payment. FCNY uses and discloses information about you to obtain payment for the services it provides on your behalf. For example, FCNY provides certain information about you to your health plan to obtain payment for its services. In addition, we may disclose your personal information to your health care providers to assist them in obtaining payment for services they have provided for you.

3. Health Care Operations. FCNY uses and discloses information about you to operate FCNY’s business. For example, FCNY uses and discloses your information to improve the quality of care you receive and to evaluate the competence and qualifications of our staff. FCNY may use and disclose information about you to your health plan to obtain authorization for the provision of additional services or to obtain a referral to a physician. FCNY also may use and disclose your information for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. FCNY may share your medical information with its "business associates" that perform administrative and other services for FCNY. FCNY has a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your information to the same extent FCNY is required to protect your information. Upon request, FCNY may share your information with other health care providers, health care clearinghouses and health plans that have a relationship with you to assist them in (i) their performance of health care quality assessment and improvement activities, (ii) their efforts to improve their provision of health care services or to reduce health care costs, (iii) their evaluation of the competence, qualifications and performance of their health care professionals, (iv) their training programs, (v) their accreditation, certification and licensing activities and (vi) their health care fraud and abuse detection and compliance efforts.

4. Notification and Communication With Family and Friends. FCNY may use your information to notify (or to enable another authorized person to notify) your family, your personal representative or another person responsible for or involved in your care about your location and your general condition. In the event of a disaster, FCNY may disclose your information to a relief organization that is coordinating notification efforts. If you are able and available to agree or object to FCNY’s disclosure of your information to the people described above, you will be given an opportunity to object to the disclosures, although FCNY may disclose your information during a disaster despite your objection if FCNY believes such disclosure is necessary to respond to the emergency. If you are unable or unavailable to agree or object, FCNY will use its best judgment when communicating with your family, friends and others.

5. Marketing. FCNY may contact you to give you information about products or services related to your treatment, case management and care coordination, or to direct or recommend other treatment or health-related benefits and services that may be of interest to you, or to provide you with small gifts. FCNY also may encourage you to purchase a product or service when we see you. FCNY will not disclose your medical information to third parties for marketing purposes without first obtaining your written authorization.

6. Fundraising. FCNY may user or disclose the following information about you to a business associate or to an institutionally-related foundation for the purpose of raising funds for FCNY’s own benefit, without an authorization from you: (i) your demographic information; and (ii) dates health care was provided to you. FCNY’s fundraising materials will include a clear and conspicuous description of how you may opt out of receiving any further fundraising communications and FCNY will ensure you do not receiving future fundraising communications if you exercise your right to opt out.

7. Required By Law. FCNY will use and disclose your information to the extent required by applicable laws, but we will limit our use and disclosure to the amount and type of information required to be disclosed. When the law requires us to report abuse, neglect or domestic violence, to respond to judicial or administrative proceedings, or to disclose your information to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

8. Public Health. FCNY may, and is sometimes required by law, to disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury or disability; reporting elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration certain problems with products and reactions to medications; and reporting disease or infection exposure. When FCNY reports suspected elder or dependent adult abuse or domestic violence, FCNY will inform you or your personal representative promptly of such report unless, in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

9. Health Oversight Activities. FCNY may, and is sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to limitations imposed by applicable laws.

10. Judicial and Administrative Proceedings. FCNY may, and is sometimes required by law, to disclose your health information in the course of an administrative or judicial proceeding. FCNY also may disclose your information in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if a court or administrative order has resolved your objections.

11. Law Enforcement. FCNY may, and is sometimes required by law, to disclose your health information to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness or missing person, or complying with a court order, warrant, grand jury subpoena or other law enforcement purpose.

12. Coroners. FCNY may, and may be required by law, to disclose your health information to a coroner in connection with his or her investigation of your death.

13. Organ or Tissue Donation. FCNY may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

14. Public Safety. FCNY may, and is sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

15. Specialized Government Functions. FCNY may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

16. Change of Ownership. If FCNY is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

17. Research. FCNY may disclose your health information to researchers if your written authorization is not required for such disclosure, as approved by an Institutional Review Board or privacy board or in compliance with governing law.

B. When FCNY Will Not Use or Disclose Your Health Information

Except as described in this notice of privacy practices, FCNY will not use or disclose health information which identifies you without your written authorization. If you do authorize FCNY to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

C. Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request in writing that FCNY restrict its use and disclosure of your health information. FCNY may accept or reject your request in its sole discretion, and will notify you of its decision. Notwithstanding the foregoing, unless otherwise required by law, FCNY will comply with your request to restrict disclosure of your health information to a health plan for purposes of carrying out payment or health care operations if the health information pertains solely to a health care item or service for which you have paid FCNY out of pocket and in full.

2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. FCNY will comply with all reasonable written requests that specify how or where you wish to receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your information, you must submit a written request detailing the information you would like to access that specifies whether you would like to inspect the information or obtain a copy of the information. If FCNY uses or maintains an electronic health record with respect to your health information, you will have the right to obtain from FCNY a copy of such information in an electronic format and, if you choose, FCNY will transmit such copy directly to an entity or other person designated by you, provided that your such choice is clear, conspicuous, and specific. FCNY will charge a reasonable fee, as allowed by law, for copies of your health information. FCNY may deny your request for access under limited circumstances.

4. Right to Amend or Supplement Your Medical Record. You have a right to request that FCNY amend information you believe is incorrect or incomplete. You must make your amendment request in writing and must include the reason you believe the information is inaccurate or incomplete. FCNY is not required to amend your health information. FCNY may deny your amendment request if it does not have the information, if it did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information or if FCNY determines the information is accurate and complete. If we deny your amendment request, we will inform you about the reasons for the denial and explain how you can respond to our denial. You also have the right to request that we add to your medical record a statement of up to 250 words concerning any information in your medical record that you believe is incomplete or incorrect.

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by FCNY, except that FCNY does not have to account for disclosures of information made to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 4 (notification and communication with family) and 14 (specialized government functions) of Section A of this notice of privacy practices, or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or disclosures to a health oversight agency or law enforcement official to the extent FCNY has received notice from such agency or official that providing an accounting would be reasonably likely to impede their activities. Notwithstanding the foregoing, on or after the effective date set forth in applicable laws, if FCNY makes a disclosure of your health information through an electronic health record for treatment, payment or health care operations purposes, upon your request, FCNY will provide you an accounting of such disclosures made by FCNY in the three year period prior to the date of your request.

6. Right to Copy of Notice. You have a right to a paper copy of this notice of privacy practices, even if you have previously requested its receipt by e-mail.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Privacy Official identified at the top of this notice.

D. Amendments To This Notice Of Privacy Practices

FCNY reserves the right to amend this notice of privacy practices at any time without prior notice. Until such amendment is made, FCNY is required by law to comply with this notice. After the notice is amended, the revised notice of privacy practices will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area and will post the current notice on our website.

E. Complaints

FCNY understands the importance of maintaining the confidentiality of your personal information. If you have any complaints about this notice of privacy practices or about how FCNY handles your health information, please contact the Privacy Official identified at the top of this notice as soon as possible so we can address your concerns. If you would like, you also may submit a formal complaint to the Secretary of the Department of Health and Human Services, Office of Civil Rights. You will not be penalized for filing a complaint with us or with the Department of Health and Human Services.