Notice Of Privacy Practices
Good Samaritan Hospital Medical Center

Effective Date: April 14, 2003

Disclosure Of Protected Health Information Related To Hiv/Behavioral/Mental Health/Drug And Alcohol And Genetic Information

This notice supplements the core Notice of Privacy Practices we are required to provide to our patients. We will provide this supplement upon request of the patient or patient representative.

We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice upon request that describes the health information privacy practices of our hospital, its medical staff, and affiliated health care providers that jointly provide health care services with our hospital related to treatment of Human Immunodeficiency Virus (HIV), Behavioral Health, Mental Health, Drug and Alcohol disease and genetic information. You will also be able to obtain your own copies by calling our office at 631-376-4138 or asking for one at the time of your next visit.

If you have any questions about this notice or would like further information, please contact Richard Rosenhagen, Privacy Officer, (631) 376-4138.

Who Will Follow This Notice?

Good Samaritan Hospital Medical Center provides health care to patients jointly with physicians and other health care professionals and organizations. The privacy practices described in this notice will be followed by:

• Any health care professional who treats you at any of our locations.
• All employees, medical staff, trainees, students or volunteers at any of our locations.
• All employees, medical staff trainees, students or volunteers at entities that are a part of Catholic Health Services (CHS) or Long Island Health Network (LIHN) that may require access to patient health information to perform a service on behalf of CHS or LIHN.
• Any business associates of our hospital.

Human Immunodeficiency Virus (HIV)

Disclosure Pursuant to a Release

• No confidential HIV-related information shall be disclosed pursuant to a general release except to insurance companies as noted in NYCRR, Title 10, Section 63.5(a)(9). Disclosure is permitted for HIV-related information pursuant to a specific release form for a limited time period that has been developed or approved by the Department of Health. The release must be signed by the protected individual, or if the protected individual lacks capacity to consent, by a person authorized pursuant to law to consent to health care for the individual.
• All written disclosures of confidential HIV information must be accompanied by a statement prohibiting redisclosure. The statement shall include the following language or substantially similar language: "This information has been disclosed to you from confidential records which are protected by state law. State law prohibits you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or as otherwise permitted by law. Any unauthorized further disclosure in violation of state law may result in a fine or jail sentence or both. A general authorization for the release of medical or other information is not, except in limited circumstances set forth in this part, sufficient authorization for further disclosure. Disclosure of confidential HIV information that occurs as the result of a general authorization for the release of medical or other information will be in violation of the state law and may result in a fine or a jail sentence or both."

Behavioral Health Including Mental Health And Drug And Alcohol

Staff members responsible for complying with this policy should be aware that special privacy protections apply to Mental Health and Drug and Alcohol Abuse information. Some steps, which are permitted or required under this policy, may not be permitted when using or disclosing these types of information. Staff members must comply with the hospital’s policies on privacy and confidentiality of Mental Health and Drug and Alcohol Abuse related information, when processing requests involving these sensitive types of information. Health Information Management Department Staff or designee members and other designated departments are expected to be aware of the requirements under those policies. When requests are made for access to designated record sets that contain these types of information, staff members must consult the other policies as well.

Genetic Information

There are several ways to gather genetic information. It can be deduced from a family’s medical history or during a physical examination. Routine laboratory tests that measure the body’s output of specific substances might also suggest the genetic make-up of the individual. But the most direct approach to obtaining genetic information is through analysis of DNA, the material that makes up genes. Such genetic tests identify specific DNA features in people who have already developed a disease, in healthy people who may be at risk of developing a genetic disorder later in life, or in people who are at risk of having a child with an inherited disorder. Thus, genetic information includes information about genes, gene products, and inherited characteristics that may derive from individuals or their family members. [Source: Department of Labor, Department of Health and Human Services, Equal Employment Opportunity Commission, Department of Justice, January 20, 1998.]

We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our privacy practices. The privacy of your medical information is important to us. Please continue to refer to the Notice of Privacy Practices you received upon registration that describes how medical information about you may be used and disclosed and how you can obtain access to this information.

Privacy Officer

Good Samaritan Hospital Medical Center
1000 Montauk Highway
West Islip, New York 11795
(631) 376-4138

Who Will Follow This Notice?
Human Immunodeficiency Virus (HIV)
Behavioral Health Including Mental Health and Drug and Alcohol
Gentetic Information
Core Notice of Privacy Practices