Notice of Privacy Practices


At the facility, we respect the privacy of your health information and are committed to maintaining its confidentiality. This notice applies to all information and records related to your care that our facility has received or created. It extends to information received or created by our employees, staff, volunteers and physicians. This notice informs you about the possible uses and disclosures of your protected health information. It also describes your rights and our obligations regarding your health information.


Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to:

  • request a restriction on certain uses and disclosures of your information for treatment, payment and health care operations. You also have the right to restrict the protected health information we disclose about you to a designated representative, family member, friend or other person who is involved in your care or the payment for your care. However, we are not required to agree to the restriction on the use of your protected health information. We must agree to your request for restriction on disclosure of your protected health information except when the release is required by transfer to another health care institution or the release is required by law. If we do agree to a restriction, we will honor that restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your treatment.
  • obtain a paper copy of the notice of information practices upon request.
  • inspect and, upon request, obtain a copy of your health and billing records. The facility may deny the request for access or to receive copies under specific conditions. Under New York State law, the facility may charge a fee for copies of the medical record.
  • request to amend your health record. You have the right to request the facility to amend any health information maintained by the facility for as long as the information is kept by or for the facility. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information was not created by the facility, unless the originator of the information is no longer available to act on our request; if the information is not part of the protected health information maintained by or for the facility; if the information is not part of the information to which you have a right of access; or if the information is already accurate and complete, as determined by the facility. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
  • obtain an “accounting” of certain disclosures of your health information. This is a listing of disclosures made by us or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.
    To request an accounting of disclosures, you must submit your request in writing and you must state the time period for which you would like the accounting. The accounting will include, if requested, the disclosure date; the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; and a brief statement of the purpose of the disclosure or certain summary information concerning multiple similar disclosures. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs for completing the accounting.
  • request communications of your health information by alternative means or at alternative locations. For example, you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.
  • revoke your authorization to use or disclose health information except to the extent that action has already been taken.


This organization is required by law to:

  • maintain the privacy of your protected health information
  • provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  • abide by the terms of the notice that is currently in effect
  • notify you if we are unable to agree to a requested restriction
  • accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information already received and maintained by the facility, as well as for all protected health information we receive in the future. Should our privacy practices change, we will post a copy of the revised notice in our facility in a clear and prominent location, as well as on our web site. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not use or disclose your health information without your authorization, except as described in this notice.


The use and disclosure of your health information for treatment, payment and healthcare operations are essential to our ability to care for you.

We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers. We will use and disclose your health information in providing you with treatment and services and to coordinate your continuing care. We may disclose your health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurses aides, lab technicians, dieticians, physical therapists and other health care providers.

*EXAMPLES WOULD INCLUDE: Information obtained by a nurse, physician or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way the physician will know how you are responding to treatment.

*A nurse caring for you will report changes in your condition to the physician.

*A pharmacist will need certain information to fill a prescription ordered by your physician.

*We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him/her in treating you once you’re discharged from our facility.

We will use or disclose your health information for payment, including for the payment activities of other health care providers or payers. We may use and disclose your health information so that we can bill and receive payment for the treatment and services you receive at the facility. For billing and payment purposes, we may disclose your health information to your representative, an insurance or managed care company, Medicare, Medicaid or another third party payer.

*EXAMPLES WOULD INCLUDE: A bill may be sent to you or a third party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

*We may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.

We will use or disclose your health information for regular health operations. We may use and disclose your health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care.

*EXAMPLES WOULD INCLUDE: Members of the medical staff or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions: (a) the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must relate to that other entity’s relationship with you; and (c) the disclosure must only be for one of the following purposes: (i) quality assessment and improvement activities; (ii) population-based activities relating to improving health or reducing health care costs; (iii) case management and care coordination; (iv) conducting training programs; (v) accreditation, licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.


As Required By Law: We may disclose your protected health information when required by law to do so.

Business Associates: There are some services provided in our organization through contacts with outside people or entities (business associates). Examples include accountants, consultants, attorneys, x-ray companies and laboratory services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third party payer for services rendered. So that your health information is protected, however, we require the business associate to appropriately safeguard your information.

Facility Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition and religious affiliation for directory purposes. Our directory does not include specific medical information about you. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. We may also use your name on a nameplate next to your door in order to identify your room, unless you notify us that you object. We may ask you to wear an armband with your name, room number and medical record number on it, unless you notify us that you object. We may label your personal care items, equipment, clothing and possessions with your name, unless you notify us that you object.

Activities: Unless you notify us that you object, our Activity Department will recognize resident’s birthdays in the newsletter, on the birthday board and on the morning announcements.

Persons Involved in Your Care or Payment for Your Care: Unless you notify us that you object, we may disclose health information about you to your designated representative, family member, close personal friend or other persons you identify, including clergy involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in arranging payment for your care. If we are unable to reach your designated representative, then we may leave a message for them at the phone number that they have provided us to return our call.

Research: Your health information may be used for research purposes, but only if: (1) the privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board and the Board can legally waive patient authorizations otherwise required by the Privacy Regulations; (2) the researcher is collecting information for a research proposal; (3) the research occurs after your death; or (4) if you give written authorization for the use or disclosure.

Transfer of Information at Death: We may disclose health information to funeral directors, medical examiners and coroners consistent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.

Marketing: We may contact you regarding your treatment, to coordinate your care or to direct or recommend alternative treatments, therapies, health care providers or settings. In addition, we may contact you to describe health related benefits and services that may be of interest to you, and the payment for such a product or service.

Fundraising: We may contact you as part of a fundraising effort.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Food and Drug Administration (FDA): We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Reporting Victims of Abuse, Neglect or Domestic Violence: If we believe that you have been a victim of abuse, neglect or domestic violence, we may disclose your health information to notify a government authority, if authorized by law or if you agree to the report.

Health Oversight Activities: We may disclose your health information to a health oversight agency for activities authorized by law. A health oversight agency is a state or federal agency that oversees the health care system. Some of the activities may include, for example, audits, investigations, inspections and licensure actions.

Judicial and Administrative Proceedings: We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a judicial subpoena, discovery request or other lawful process.

Disaster Relief: We may disclose health information about you to an organization assisting in a disaster relief effort.

Treatment Alternatives and Health-Related Benefits and Services: We may use or disclose your health information to inform you about treatment alternatives and health- related benefits and services that may be of interest to you.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law to comply with reporting requirements, to comply with a court order, warrant, judicial subpoena, or summons, to identify or locate a suspect, fugitive, material witness or missing person, when information is requested about the victim of a crime if the individual agrees or under other limited circumstances, to report information about a suspicious death, to provide information about criminal conduct occurring at the facility, to report information in emergency circumstances about a crime or when necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.

To Avert a Serious Threat to Health or Safety: When necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person, we may use or disclose your health information to someone able to help lessen or prevent the threatened harm.

Military and Veterans: If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may also use and disclose health information about you if you are a member of a foreign military as required by the appropriate foreign military authority.

National Security and Intelligence Activities; Protective Services for the Patient and Others: We may disclose health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.

Inmates/Law Enforcement Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the institution or official for certain purposes including your own health and safety as well as that of others.


We will use and disclose protected health information (other than as described in this notice or required by law) only with your written authorization.

A written authorization is designed to inform you of a specific use or disclosure, other than those set forth above, that we plan to make of your health information. The authorization describes the particular health information to be used or disclosed and the purpose of the use or disclosure. Where applicable, the written authorization will also specify the name of the person to whom we are disclosing the health information. The authorization will also contain an expiration date or event.

You may revoke your authorization to use or disclose protected health information in writing, at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization.


If you have questions and would like additional information concerning your privacy rights, you may contact the Director of Health Information Management/Privacy Officer at (716) 434-6324, ext. 3029.

If you believe your privacy rights have been violated, you can file a complaint with the facility. These complaints must be filed in writing on a form provided by our facility. The complaint form may be obtained from the Privacy Officer and when completed should be returned to the Privacy Officer. You may also file a complaint with the office of civil rights in the United States Department of Health and Human Services. There will be no retaliation for filing a complaint.

Effective April 14, 2003