Notice of Privacy Practices

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ABVI-GOODWILL

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Effective Date: 4/15/2013

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:

If you have any questions or wish to receive additional information about the matters covered by this Notice of Privacy Practices, please contact the Privacy Officer at (585) 232-1111.

The Association for the Blind and Visually Impaired-Goodwill of Greater, Rochester, Inc. (the "Covered Entity") known as ABVI-Goodwill is required to abide by the terms of this Notice of Privacy Practices (this "Notice"). ABVI-Goodwill reserves the right to change the terms of this Notice at any time. The revised Notice will apply to all protected health information ABVI-Goodwill received or created in the past as well as all protected health information ABVI-Goodwill receives or creates in the future. A current copy of the Notice will be available at the receptionist desk of the Low Vision Center waiting room, the receptionist desk of the ABVI-Goodwill lobby and on our website www.seegreatthings.com. You may also call the Low Vision Center at (585) 697-5736 and request that one be sent to you. The effective date of this Notice of Privacy Practices is set forth on the first page of this Notice.

Your "protected health information" consists of all individually identifiable information which is created or received by ABVI-Goodwill and which relates to your past, present or future physical or mental health of condition, the provision of health care to you or the past, present or future payment for health care provided to you.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WHICH YOUR CONSENT OR AUTHORIZATION IS NOT REQUIRED

1. Treatment: ABVI-Goodwill will use and disclose your protected health information to provide, coordinate or manage your health care and related services by ABVI-Goodwill and other health care providers, including consulting with other health care providers about your health care or referring you to another health care provider for treatment. For example, ABVI-Goodwill will disclose your protected health information to a specialist to whom you have been referred to ensure that the specialist has the necessary information he or she needs to diagnose and/or treat you.

2. Payment: ABVI-Goodwill will use and disclose your protected health information, as needed, to obtain payment for the health care ABVI-Goodwill provides to you. For example, prior to providing services, ABVl-Goodwill may disclose to your insurance carrier the treatment you are going to receive to ensure that your insurance carrier will cover that treatment. Additionally, ABVI-Goodwill may disclose to your insurance carrier, as necessary, the treatment you received to ensure that ABVI-Goodwill is paid or you are reimbursed for the cost of your treatment.

3. Health Care Operations: ABVI-Goodwill may use or disclose your protected health information in order to support the business activities of ABVI-Goodwill. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, conducting training programs in which students provide treatment under the supervision of one of ABVI-Goodwill's physicians, business planning and development and business management and general administrative activities. Additionally, ABVl-Goodwill may use your protected health information to ensure that all of the physicians at ABVl-Goodwill provide the highest quality health care.

4. Appointment Reminders: ABVl-Goodwill may use or disclose your protected health information in order to contact you and remind you of a scheduled appointment.

5. Business Associates: We may disclose protected health information to our business associates that perform functions on our behalf or to provide us with services if the information is necessary for such functions or services. For example, at your request, we may use or disclose your protected health information to arrange transportation to appointments or to utilize interpreting services. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than what is specified in our contract.

6. Treatment Alternatives: ABVl-Goodwill may use or disclose your protected health information to inform you about treatment alternatives.

7. Health Related Benefits and Services: ABVI-Goodwill may use and disclose your protected health information to inform you about health-related benefits and services that may be of interest to you.

8. Fundraising Activities: ABVI-Goodwill may use your health information for fundraising communications. You have the right to opt out of such communications with each solicitation. If you do not wish to be contacted for fundraising purposes, please contact the Development Office at (585) 697-5711.

9. Others Involved in Your Health Care and Disaster Relief: Unless you object, ABVI-Goodwill may disclose to a family member, other relative, close personal friend or any other person identified by you, protected health information related to that person's involvement in your health care or payment related to your health care. ABVI-GoodwiII may also use or disclose to a person responsible for your care your protected health information that relates to your location, general condition or death. If the opportunity for you to agree or object to any such disclosure cannot be provided due to emergency circumstances, ABVI-Goodwill will make these disclosures if they are in your best interests. Additionally, ABVI-GoodwiII may disclose protected health information relating to your location, general condition or death to any public or private entity authorized to assist in disaster relief efforts.

10. Public HeaIth: ABVI-Goodwill may disclose your protected health information to a public health authority authorized to collect such information for the purpose of:
a. preventing or controIIing disease, injury or disability;
b. reporting disease or injury;
c. reporting vital events such as births or deaths;
d. conducting public health surveillance, public health investigations and public health interventions;
e. at the direction of a public health authority, to an official of a foreign government agency acting in collaboration with a public health authority; or
f. Reporting child abuse or neglect.

11. Food and Drug Administration: ABVI-Goodwill may disclose your protected health information to a person subject to the jurisdiction of the Food and Drug Administration ("FDA") for the purpose of activities related to the quality, safety or effectiveness of FDA regulated products.

12. Communicable Diseases: ABVI-Goodwill may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of spreading a disease or condition.

13. Employer: ABVI-Goodwill may disclose your protected health information to your employer if ABVI-Goodwill is providing health care to you at the request of your employer to conduct an evaluation relating to medical surveillance relating to your workplace or to evaluate whether you have a work related illness or injury. ABVI-Goodwill will notify you before your protected health information relating to the medical surveillance of the workplace and work-related illnesses and injuries are disclosed to your employer by providing you with written notice at the time ABVI-Goodwill renders health care to you.

14. Abuse, Neglect or Domestic Violence: ABVI-Goodwill may disclose your protected health information to a government authority authorized to receive reports of abuse, neglect or domestic violence if ABVI-Goodwill reasonably believes that you are a victim of abuse, neglect or domestic violence. Any such disclosure will be made (1) to the extent it is required by law, (2) to the extent that the disclosure is authorized by statute or regulation and ABVI-Goodwill believes the disclosure is necessary to prevent serious harm to you or other potential victims or (3) if you agree to the disclosure.

15. Health Oversight Activities: ABVl-Goodwill may disclose your protected health information to a health oversight agency for any oversight activities authorized by law, including audits; investigations; inspections; licensure or disciplinary actions; civil, criminal or administrative actions or proceedings; or other activities necessary for the oversight of the health care system, government benefit programs, compliance with government regulatory program standards or compliance with applicable civil rights laws.

16. Judicial and Administrative Proceedings: ABVI-Goodwill may, upon certain conditions, disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, a subpoena, discovery request, or other lawful process.

17. Law Enforcement Purposes: ABVl-Goodwill may disclose your protected health information for law enforcement purposes to a law enforcement official:

a. In compliance with a court order, a court-ordered warrant, a subpoena or summons issued by a judicial officer or an administrative request;
b. In response to a request for information for the purposes of identifying or locating a suspect, fugitive, material witness or missing person;
c. In response to a request about an individual that is suspected to be a victim of a crime, if, under limited circumstances, ABVl-Goodwill is not able to obtain your consent;
d. If the information relates to a death ABVI-Goodwill believes may have resulted from criminal conduct;
e. If the information constitutes evidence of criminal conduct that occurred on the premises of ABVI-Goodwill; and
f. In certain emergency circumstances, to alert law enforcement of the commission and nature of a crime, the location and victims of the crime and the identity, or description and location of the perpetrator of the crime.

18. Coroners, Medical Examiners and Funeral Directors: ABVI-Goodwill may disclose your protected health information to a coroner or medical examiner for the purpose of identifying you, determining a cause of death or other duties authorized by law. ABVI-Goodwill may disclose your protected health information to a funeral director, consistent with all applicable laws, in order to allow the funeral director to carry out his or her duties.

19. Organ and Tissue Donation: ABVI-Goodwill may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating organ, eye and tissue donation and transplantation.

20. Medical Research: ABVI-GoodwiII may disclose your protected health information for research purposes, provided that an institutional review board authorized by law or a privacy board waives the authorization requirement and provided that the researcher makes certain representations regarding the use and protection of the protected health information to be disclosed.

21. Serious Threat to Health or Safety: ABVI-Goodwill may disclose your protected health information, in a manner which is consistent with applicable laws, if the disclosure is necessary to prevent or lessen a serious threat to health or safety or the information is necessary to apprehend an individual.

22. Inmates: ABVI-Goodwill may disclose your protected health information to a correctional institution or a law enforcement official having lawful custody of you if the correctional institution or law enforcement official represents that the information is necessary to (1) provide health care to you; (2) the health and safety of other inmates; (3) the health and safety of the officers and employees of the correctional institution or the people responsible for transporting the inmates; (4) law enforcement on the premises of the correctional institution; or (5) the administration and maintenance of the safety, security and good order at the correctional institution.

23. Workers' Compensation: ABVI-Goodwill may disclose your protected health information as authorized by, and in compliance with, laws relating to workers' compensation and other similar programs established by law that provide benefits for work-related illnesses and injuries without regard to fault.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any use or disclosure of your protected health information that is not listed above will be made only with your written authorization including:

a. Uses and disclosures for marketing purposes.
b. Uses and disclosures that constitute the sale of PHI.

You have the right to revoke your authorization at any time, except to the extent that ABVI-Goodwill has already used or disclosed your protected health information in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

1. Restriction of Use and Disclosure: You have the right to request that ABVI-Goodwill restrict the protected health information ABVI-Goodwill uses and discloses in carrying out treatment, payment and health care operations. You also have the right to restrict the protected health information ABVI-Goodwill discloses to a family member, other relative or any other person identified by you, which is relevant to such person's involvement in your treatment or payment for your treatment. ABVI-Goodwill is not obligated to agree to any restriction that you request unless the disclosure is to a health plan for purposes of payment for healthcare services or healthcare operations. In this case, we must agree to your request; however, you must have paid us in full “out of pocket” in order for us to grant the disclosure restriction. We are not required to agree to your request if it relates to your treatment; however, if we do agree, we are bound by our agreement except when otherwise required by law, emergencies, or when the information is necessary to treat you. If you wish to request a restriction on the use and disclosure of your protected health information, please send a written request to the Privacy Officer which specifically sets forth (1) whether you are restricting the use or the disclosure of your protected health information, (2) what protected health information you wish to limit, and (3) to whom you wish the limits to apply (i.e., your spouse). ABVl-Goodwill will not ask why you are requesting the restriction. The Privacy Officer will review your request and notify you whether or not ABVl-Goodwill will agree to your requested restriction.

2. Confidential Communications: You have the right to request that you receive communications of your protected health information from ABVI-Goodwill in alternative means or at alternative locations. ABVl-Goodwill will accommodate all reasonable requests. To request that ABVI-Goodwill make communications of your protected health information by alternative means or at alternative locations, please send a written request to the Privacy Officer setting forth the alternative means by which you wish to receive communications or the alternative location at which you wish to receive such communications. ABVI-Goodwill will not ask why you are making such a request. When appropriate, ABVI-Goodwill may condition the provision of a reasonable accommodation upon receiving information relating to how payment, if any, will be received.

3. Access to Protected Health Information: You have the right to inspect and obtain a copy of your protected health information that ABVI-Goodwill maintains in a designated record set, for so long as that protected health information is maintained in a designated record set. A "designated record set" is a group of records maintained by or for ABVI-GoodwiIl, which includes billing records and records used in whole or in part to make decisions about you. You do not have the right to inspect or copy psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or information that ABVI-Goodwill is otherwise prohibited by law from disclosing. If you wish to inspect or obtain a copy of your protected health information, please send a written request to the Privacy Officer. If you request a copy of your protected health information, ABVI-Goodwill may charge a fee for the cost of copying and mailing the information. ABVI-Goodwill may, for certain limited reasons, deny your request to inspect or obtain a copy of your protected health information. If ABVI-Goodwill denies your request, you may be entitled to a review of that denial. If you are entitled to a review and you wish to have ABVI-Goodwill's decision reviewed, please contact the Privacy Officer. The Privacy Officer will designate a licensed health care professional to review your request. This reviewing health care professional will not have participated in the original decision to deny your request. ABVI-Goodwill will comply with the decision of the reviewing health care professional.

4. Amending Protected Health Information: You have the right to request that ABVI-Goodwill amend your protected health information in a designated record set for so long as that information exists in a designated record set. To request that an amendment be made to your protected health information, please send a written request to the Privacy Officer. Your written request must provide a reason that supports the requested amendment. ABVI-Goodwill may deny your request if it does not contain a reason that supports the requested amendment. Additionally, ABVI-Goodwill may deny your request to have your protected health information amended if ABVI-Goodwill determines that (1) the information was not created by ABVI-Goodwill, unless the person or entity that created the information is no longer available to make the amendment; (2) the information is not part of a designated record set; (3) the information is not available for your inspection; or (4) the information is accurate and complete.

5. Accounting of Disclosures of Your Protected Health Information: All of our individuals served have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of disclosures our organization has made of your protected health information. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer at 422 South Clinton Avenue, Rochester, NY 14620. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of your request. The first list you request within a 12-month period is free of charge, but our organization may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Breach Notification: You have the right to receive notification of a breach of your unsecured protected health information.

7. Obtaining a Copy of this Notice: You have the right to request and receive a paper copy of this Notice of Privacy Practices from ABVI-Goodwill at any time.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with ABVI-Goodwill or with the Secretary of Health and Human Services. To file a complaint with ABVI-Goodwill, please contact the Privacy Officer at (585) 232-1111. All complaints must be submitted in writing.

THE AGENCY WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.