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THIS NOTICE DESCRIBES HOW YOUR PERSONAL HEALTH INFORMATION MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
The House of the Good Shepherd (HGS) is required by law to maintain the privacy of your health information
and to provide you with notice of its legal duties and privacy practices with respect to your health information.
If you have questions about any part of this notice or if you want more information about the privacy practices
at The House of the Good Shepherd please contact Zig Malowicki, Privacy Officer, in writing, at 1550
Champlin Avenue, Utica, New York 13502; or by telephone at 315-235-7602.
Effective Date of This Notice: April 14, 2003
I. Responsibilities of The House of the Good Shepherd Under the Federal Privacy Standard:
The House of the Good Shepherd is required to:
- Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative and technical safeguards to protect the information.
- Provide you with this notice as to the HGS legal duties and privacy practices with respect to individually identifiable personal health information we collect and maintain about you.
- Abide by the terms of this notice and train our personnel concerning your privacy and confidentiality.
- Implement a sanction policy to discipline those who breach privacy/confidentiality or the HGS policies concerning privacy/confidentiality.
- Mitigate (lessen the harm of) any breach of privacy/confidentiality.
II. Understanding Your Behavioral Health Record Information:
The House of the Good Shepherd makes a record of all services provided to you. Typically this record
contains your health history, current symptoms, examination and test results, diagnoses, treatment and
a plan for future care or treatment. This information, often referred to as your medical record, serves
as a basis for your care and treatment, a means of communication among the many health
professionals who contribute to your care, and a legal document describing the care you receive. This
record also serves as a means by which a third-party payer can verify you actually received the
services billed for and a source of information to assess the appropriateness and quality of the care
you receive and a tool to improve the quality of healthcare.
III. The House of the Good Shepherd May Use or Disclose Your Health Information:
The House of the Good Shepherd collects health information from you and stores it in a paper chart
and on a computer. This is your medical record. The medical record is the property of The House of
the Good Shepherd, but the information in the medical record belongs to you. The House of the Good
Shepherd makes every reasonable effort to protect the privacy of your health information. The law
permits The House of the Good Shepherd to use or disclose your health information for the following
- Treatment: HGS will use your treatment and health information to create assessments,
treatment plans and progress notes that provide information to our staff and other health
service providers who contribute to your treatment, including physicians, psychologists, social
workers, dentists, pharmacists and other medical or mental health professionals responsible
for providing your medical needs. An example of disclosing personal health information would
be sending copies of your treatment records to a healthcare provider in order to provide
treatment that is not available at HGS, or sending medical records to a physician that may
have to treat you for an injury or an illness while you are enrolled at HGS. Per New York State
Mental Hygiene Law, and Social Services Law, HGS shall not disclose written information
concerning your treatment without a signed authorization to do so from you or your
- Payment: The House of the Good Shepherd may share your health information to procure
payment for your treatment or to pay others who may provide treatment in addition to that
provided at the House of the Good Shepherd. An example of this would be a County
responsible for paying the House of the Good Shepherd for your treatment may require a copy
of your progress notes prior to paying for your treatment.
- Regular Health Care Operations: HGS will use your treatment and health records for
healthcare operations including quality analysis, quality improvement and peer review. An
example of this would be if a member of the medical staff or the Director of Quality
Improvement uses information in your health record to assess the quality of care and
outcomes, and the competence of care-givers. HGS will use this information in an effort to
continually improve the quality and effectiveness of the services we provide.
- Permission to Release Information: HGS requires a signed authorization to release
information from you or your parent/guardian prior to releasing information for purposes other
than those listed above or as otherwise permitted or required by federal or state law.
- Notification and Communication with Family: HGS may disclose your health information to
notify or assist in notifying your parent/guardian, your personal representative or another
person responsible for your care about your location, your general condition, or in the event of
your death. If you are able and available to agree or object, we will give you the opportunity to
object prior to making this notification. If you are unable or unavailable to agree or object, our
health professionals will use their best judgment in communication with your family and others.
- Required by Law: HGS may use and disclose your health information as required by federal,
state and local law.
- Public Health: HGS may disclose your health information as allowed or required by law, to
public health authorities for purposes related to: preventing or controlling disease, injury or
disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food
and Drug Administration problems with products and reactions to medications; and reporting
disease or infection exposure.
- Health Oversight and Public Authorities: HGS may disclose your health information to health
oversight agencies during the course of audits, investigations, inspections, licensure and other
- Judicial and Administrative Proceedings: HGS may disclose your health information, as
required by law, in the course of administrative or judicial proceedings.
- Law Enforcement: HGS may disclose your health information to a law enforcement official for
purposes such as identifying or locating a suspect, fugitive, material witness or missing
person, complying with a court order or subpoena, and other law enforcement purposes.
- Deceased Person Information: We may disclose your health information to coroners, medical
examiners, and funeral directors.
- Organ donation: HGS may disclose your health information to organizations involved in
procuring, banking, or transplanting organs and tissues.
- Research: HGS may disclose your health information to researchers conducting research that
has been approved by an Institutional Review Board or The House of the Good Shepherd's
research review committee.
- Public Safety: HGS may 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.
- Fund-raising: HGS may contact you to participate in fund-raising activities for The House of
the Good Shepherd.
- Change of Ownership: In the event that The House of the Good Shepherd is sold or merged
with another organization, your health information/record will become the property of the new
IV. The House of the Good Shepherd May Not Use or Disclose Your Health Information in the Following Circumstances:
The House of the Good Shepherd will not use or disclose your health information without your written
authorization, except as described in this Notice of Privacy Practices. If you do authorize The House
of the Good Shepherd to use or disclose your health information for another purpose, you may revoke
your authorization in writing at any time.
V. Your Health Information Rights:
- Right to Restrict Use and/or Disclosure: You or your parent/guardian have the right to request
restrictions on certain uses and disclosures of your health information. This right does not
extend to activities necessary to carry out the operations of The House of the Good Shepherd
or to those mandated by law. HGS is not required to agree to the restriction that you
requested, however, if we do agree, we will adhere to the agreement unless you request
otherwise or HGS provides advance notice.
- Right to Confidential Communications: You or your parent/guardian have the right to receive
your health information through a reasonable alternative means or at an alternative location.
This request should be in writing and submitted to the assigned Primary Therapist.
- Right to Access Information: You or your parent/guardian have the right to inspect and copy
your health information. This right is not absolute. HGS may deny access in certain
situations, such as instances where access may cause harm to you or others. HGS reserves
the right to charge a reasonable, cost-based fee for making copies.
- Right to Request Amendments: You or your parent/guardian have a right to request that The
House of the Good Shepherd amend your health information that is incorrect or incomplete.
The House of the Good Shepherd is not required to change your health information if we did
not create the record or if the record is accurate and complete. HGS will provide you with
information about The House of the Good Shepherd’s denial and how you can disagree with
the denial. If we grant your request, we will make the correction and distribute the correction
to those that need it and those that you identify to us that you want to receive the corrected
- You or your parent/guardian have a right to receive an accounting of disclosures of your
health information made by The House of the Good Shepherd, except that The House of the
Good Shepherd does not have to account for disclosures described above for treatment, payment, health care operations, information provided to you, facility directory listings and
certain government functions.
- You or your parent/guardian have a right to a paper copy of this Notice of Information
- 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 assigned Primary Therapist.
VI. Changes to this Notice of Privacy Practices:
The House of the Good Shepherd reserves the right to amend this Notice of Information Practices
at any time in the future, and to make the new provisions effective for all information that it maintains,
including information that was created or received prior to the date of such amendment. Until such
amendment is made, The House of the Good Shepherd is required by law to comply with this Notice.
If this notice is revised, it will be delivered to you or your parent/guardian by your Primary Therapist
and you will be given a new version of the House of the Good Shepherd's Notice of Information
Complaints about this Notice of Information Practices or how The House of the Good Shepherd
handles your health information should be directed to: Zig Malowicki, Privacy Officer, in writing, at
1550 Champlin Avenue, Utica, New York 13502; or by telephone at 315-235-7600 Extension 7602.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a
formal complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You may also address your compliant to one of the regional Offices for Civil Rights. A list of these
offices can be found online at http://www.hhs.gov/ocr/regmail.html.