SISSELMAN MEDICAL GROUP, PC
Notice of Privacy Practices
Effective Date: August 24, 2016
Uses and Disclosures. 5
Treatment, Payment and Operations. 5
Appointments and Reminders. 6
Opportunity to Agree or Object 6
Friends and Family. 6
Facility Directory. 6
Business Associates. 7
Public Policy. 7
Required by Law.. 7
Public Health Activities. 7
Law Enforcement 8
Cadaveric Organ, Eye or Tissue Donation. 8
Threats to Health or Safety. 8
Governmental Functions. 8
Workman’s Compensation. 9
Your Rights. 9
Right to Notice. 9
Right to Request Restrictions. 9
Right to Confidential Communications. 9
Right of Access to PHI. 10
Right to Amend PHI. 10
Right to an Accounting of PHI Disclosures. 10
Our Duties. 10
Questions and Requests for Information. 11
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.
SISSELMAN MEDICAL GROUP, PC. (“SMG”) is committed to providing quality
healthcare services to you. An important part of that is protecting your medical
information according to applicable law. This notice (“Notice”) describes
your rights and our duties under Federal Law, as well as other pertinent information. We
are happy to answer any questions you may have regarding this Notice. Our staff will
briefly review the key points contained herein once you have had an opportunity to read
- Healthcare Operations. “Healthcare Operations” means
business activities that we engage in so as to provide healthcare services to you,
including but not limited to, quality assessment and improvement activities,
personnel training and evaluation, business planning and development, and other
administrative and managerial functions.
- Payment. “Payment” means activities that we undertake
as a healthcare provider to obtain reimbursement for the provision of healthcare to
you which include, but are not limited to: determinations of eligibility or coverage
(including coordination of benefits or the determination of cost sharing amounts),
and processing health benefit claims.
- Protected Health Information. “Protected Health Information”
or “PHI” means information which identifies you (e.g. name, address,
social security number, etc.) and relates to your past, present, or future physical
or mental health or condition; the provision of healthcare to you; or the past,
present, or future payment for the provision of healthcare to you.
- Treatment. “Treatment” means the provision,
coordination, or management of healthcare and related services on your behalf,
including the coordination or management of healthcare with a third party;
consultation between SISSELMAN MEDICAL GROUP and other healthcare providers relating
to your care; or the referral by SISSELMAN MEDICAL GROUP of your care to another
There are three instances where an Authorization is required from you before we disclose
your PHI: (1) most Uses and Disclosures of psychotherapy notes; (2) Uses and Disclosures
for marketing purposes; and (3) Uses and Disclosures that involve the sale of PHI.
There are a number of Disclosures that do not require your Authorization: (1) public
health activities; (2) research purposes; (3) your treatment; (4) the sale, transfer,
merger or consolidation of all or part of our organization and for related due
diligence; (5) services rendered by a business associate pursuant to a business
associate contract and at the specific request of our organization; (6) providing you
with access to your PHI; and (7) other purposes that the Secretary of the Department of
Health and Human Services deems necessary and appropriate.
You may, at your own discretion, provide us with other Authorizations. It is our Policy
only to use and disclose PHI requiring an Authorization consistent with the
Authorization as provided by you. Our Compliance Officer will ensure that all
Authorizations meet the requirements of the Privacy Rule and that our staff is trained
regarding those instances of Uses and Disclosures wherein Authorizations are
Uses and Disclosures
Uses and disclosures of your protected health information (“PHI”) may be
permitted, required, or authorized. Examples are provided below under various categories
to give you a sense of how we may use and/or disclose your PHI.
Treatment, Payment and Operations
We will use and/or disclose your PHI as follows: 1) to ensure that we appropriately
provide for your care and Treatment; 2) to obtain Payment for our services; and 3) as
necessary to conduct our Healthcare Operations.
Our staff, including doctors, nurses and other clinicians, will use your PHI to order
tests, procedures, and medications; and to otherwise provide for your care. We may
disclose your PHI to pharmacies and other healthcare providers as needed. For example,
we may disclose your PHI when we refer you to another healthcare provider.
Your PHI will be used to check for eligibility for insurance coverage and prepare claims
for your insurance company where appropriate. We may also use your PHI to invoice you
directly or to invoice a government agency on your behalf. For example, in order to
prepare invoices, we will disclose information regarding your treatment, the conditions
you were treated for, and when you were treated.
We may use and disclose your PHI in order to conduct our healthcare business and to
perform functions associated with our business activities. For example, your PHI may be
disclosed when we train staff, conduct quality improvement activities, and develop
business plans. Your PHI may also be shared with business associates who perform certain
business functions on our behalf such as billing, transcriptions and electronic PHI
transmissions with other healthcare providers.
Appointments and Reminders
We may use your PHI to contact you regarding appointment reminders or information about
treatment alternatives or other health-related benefits and services that may be of
interest to you.
Opportunity to Agree or Object
Under certain circumstances, we may only use and disclose your PHI with your permission
as directly provided by you, or in a context wherein we can reasonably infer it, unless
you are not present, are incapacitated, or an emergency exists, in which case we are
compelled by law to use our professional judgment to determine when to use your PHI, and
the extent to which it is used. The following are examples of when you will have an
opportunity to agree or object.
Friends and Family
In your presence, we may only disclose your PHI to friends and family with your express
permission. For example, we will request that you grant us express permission before
discussing your PHI in the company of friends and family. If you elect not to proceed,
then friends and family will be excluded from any such conversation. In emergency
circumstances, or if you are not present to agree or object, then we will use our
professional judgment regarding those communications.
We may use or disclose your PHI to notify, or assist in the notification of (including
identifying or locating), a family member, a personal representative, or another person
responsible for your care. Any such use or disclosure of your PHI for notification
purposes will be made consistent with this policy and applicable law. For example, such
notification will only proceed with your permission if you have the capacity to grant
it, otherwise the required notification will be guided by our professional judgment.
We may use or disclose your PHI to a business associate that performs a business function
on our behalf and requires your PHI in order to do so. Such use or disclosure will only
occur after performing due diligence to ensure that the business associate is meeting
all statutory and contractual requirements. A written contract will be executed with
each business associate, and will be reviewed on a yearly basis, to ensure that the
business associate is providing adequate PHI safeguards.
There are a number of uses and disclosures that we are required or permitted to make for
public policy reasons. The following is a representative list of uses and disclosures
that fall under this category.
Required by Law
We may use or disclose your PHI to the extent that such use or disclosure is required by
law. In such cases, the use or disclosure will be limited to uses and disclosures
pertaining to the relevant requirements of such law.
Public Health Activities
We may disclose your PHI to governmental authorities for public health activities and for
purposes described as follows:
- preventing or controlling disease, injury, or disability, including, but not limited
to, the reporting of disease, injury, vital events such as birth or death, and the
conduct of public health surveillance, public health investigations, and public
health interventions; or, at the direction of a public health authority, to an
official of a foreign government agency that is acting in collaboration with a
public health authority;
- reporting child abuse or neglect;
- activities related to the quality, safety or effectiveness of a Food and Drug
Administration regulated product or process;
- to persons who may have been exposed to a communicable disease or may otherwise be
at risk of contracting or spreading a disease or condition, if we are authorized by
law to notify such persons as necessary in the conduct of a public health
intervention or investigation; or
- to an employer, about an individual who is a member of the workforce of the
employer, under a limited set of conditions.
We may disclose your PHI for law enforcement purposes to a law enforcement official, but
only if certain specified conditions are met. For example, we may disclose your PHI to
law enforcement for purposes of identification and for purposes related to a crime.
We may disclose PHI to a coroner, medical examiner or funeral director for the purpose of
identifying a deceased person, determining a cause of death, or otherwise carrying out
their duties as authorized by law.
Cadaveric Organ, Eye or Tissue Donation
We may disclose PHI to organ procurement organizations or other entities engaged in the
procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the
purpose of facilitating organ, eye or tissue donation and transplantation.
We may use or disclose your PHI for research, regardless of the source of funding of the
research, provided that certain conditions are met, including but not limited to the
approval of an Institutional Review Board and consistent with applicable law.
Threats to Health or Safety
We may, consistent with applicable law and standards of ethical conduct, use or disclose
your PHI if we have a good faith belief that the use or disclosure is necessary to
prevent or lessen a serious and imminent threat to the health or safety of a person or
the public or is required by law enforcement authorities to identify or apprehend an
We may use or disclose your PHI for the following governmental functions as long as
certain specified conditions are met: 1) military and veterans activities; 2) national
security and intelligence activities; 3) protective services for the President and
others; 4) medical suitability determinations for a covered entity that is a component
of the Department of State; 5) correctional institutions and other law enforcement
custodial situations; and 6) covered entities that are government programs providing
We may disclose your PHI as authorized by and to the extent necessary to comply with laws
relating to workers’ compensation or other similar programs, established by law,
that provide benefits for work-related injuries or illness without regard to fault.
Federal law and or New York State law provides you several important rights regarding
your PHI. The following sections summarize your rights and provide information regarding
how to exercise them. Protecting your PHI is an important part of the services we
provide you. We want to ensure that you have access to your PHI when you need it and
that you clearly understand your rights as described below.
Right to Notice
You have a right to adequate notice of the uses and disclosures of your PHI, and our
duties and responsibilities regarding same, as provided for herein. You have a right to
request both a paper and electronic copy of this Notice.
Right to Request Restrictions
You have a right to request restrictions on how we use and disclose your PHI for
treatment, payment and operations, as well as regarding those instances where you have
an opportunity to agree or object. We are not required to agree to restrictions for
treatment, payment and operations except in limited circumstances. If we do agree to a
restriction of any kind then we will honor it going forward, unless you take affirmative
steps to revoke it or we believe, in our professional judgment, that an emergency
warrants circumventing the restriction in order to provide the appropriate care. In rare
circumstances, we reserve the right to terminate a restriction that we have previously
agreed to, but only after providing you notice of termination.
You have a right to restrict certain disclosures of PHI to a
health plan where you have paid out of pocket in full for the healthcare item or
service. You are required to notify all downstream healthcare providers (e.g. a
pharmacist) and business associates, including Health Information Exchange(s), of the
restriction. We are required by law to honor this restriction and will do so unless
affirmatively terminated by you in writing.
Right to Confidential Communications
You have a right to request alternative communication methods with respect your health
matters and related PHI. We ask that you make such communication requests in writing. We
will honor all reasonable requests consistent with our duty to ensure that your PHI is
Right of Access to PHI
You have a right to access, inspect and obtain a copy of your PHI except where excluded
by applicable law. All requests for access to your PHI must be made in writing. Under a
limited set of circumstances, we may deny your request. Any denial of a request to
access will be communicated to you in writing. In general, you have a right to have a
denial reviewed by a licensed third party healthcare professional (i.e. one not
affiliated with us). We will comply with the decision made by the designated
professional. We may charge you a reasonable fee for providing you a copy of your
Right to Amend PHI
You have a right to request that we amend your PHI for as long as it is maintained by us.
The request must be made in writing and you must provide a reason to support the
requested amendment. Under certain conditions we may deny your request to amend,
including but not limited to, when the PHI: 1) was not created by us; 2) is excluded
from access and inspection under applicable law; or 3) is accurate and complete. If we
accept the amendment we will work with you to identify other healthcare stakeholders
that require notification and provide the notification. If we deny the amendment, we
will provide the rationale for denial to you in writing and afford you the opportunity
to submit a statement of disagreement.
Right to an Accounting of PHI Disclosures
You have right to receive an accounting of your PHI disclosures made by us during a time
period specified by applicable law prior to the date on which the accounting is
requested. You must make any request for an accounting in writing. Certain PHI is
excluded from an accounting by law and therefore will not be provided. One accounting
within any twelve (12) month period will be provided to you at no charge. Additional
accountings may require that you pay us a reasonable fee. We will notify you of the fee
to be charged (if any) at the time of the request.
We are required by law to: 1) maintain the privacy of your PHI; 2) provide you with this
Notice of our privacy practices; 3) abide by the terns of the Notice currently in
effect; and 4) modify this Notice when there are material changes to your rights, our
duties, or other practices contained herein. This Notice will remain in effect until it
We reserve the right to change our privacy practices and the terms of this Notice
consistent with applicable law and our current business processes. Should we make
revisions to this Notice, we will provide you notification as follows: 1) upon request;
2) electronically via our website or via other electronic communications; and 3) as
posted in our place of business. Any modifications to our Notice will apply
retroactively to your entire PHI, as maintained by us.
In addition to the above, we have an affirmative duty to respond to your requests (i.e.
those corresponding to your rights) in a timely and appropriate manner. We support and
value your right to privacy and are committed to maintaining reasonable and appropriate
safeguards for your PHI. We will not retaliate in any way shape or form should you
decided to file a complaint with us or with the Department of Health and Human
Questions and Requests for Information
Questions, requests for information, and other inquiries under this Notice should be
directed to us as follows:
SISSELMAN MEDICAL GROUP, PC
Attn: Privacy Officer
Massapequa, NY 11758
516-308-4040 – tel
516-804-6386 - fax
If you believe that your rights have been violated, then you may submit a formal written
complaint to us using the contact information provided above.
You may also send a written complaint directly to the Department of Health and Human
Services (“HHS”) by using its Health Information Privacy Complaint Package.
If you have questions regarding how to file a complaint with HHS you may contact the
agency via email at OCRMail@hhs.gov or visit the
HHS website at www.hhs.gov.
We reserve the right make modifications to our policies and procedures, including to this
Notice, as necessary and appropriate to comply with applicable law, including the
standards, implementation specifications, and other requirements of the HIPAA Privacy
Print Name Date