Offering the finest in specialty Clinical Services & Vocational Training since 1986
A proud member of the UI Rehab family of companies
Notice of Privacy Practices
Universal Institute/Therapeutic Rehabilitation (UI/TR) is committed to and required by law to maintain the privacy of your health information. This Notice will describe how UI/TR may use and disclose your protected health information. This Notice also sets out UI/TR’s legal obligations concerning your protected health information and describes your rights to control and access your health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH). This Notice of Privacy Practices applies to all departments and services being provided by UI/TR at all locations. The departments may share your health care information with each other, as necessary to carry out treatment, payment or health care operations.
UI/TR will designate a competent individual as Privacy Officer. UI/TR may designate a different individual as privacy officer as necessary and will inform all clients and staff of such changes. The current Privacy Officer is:
Michael Scudillo, OTR, CHC
15-17 Microlab Rd. Suite 101
Livingston, NJ 07039
973-992-8181 Ext. 26
Fax – 973-992-7178
How We May Use and Disclose your Health Information:
We may use and disclose your health information as described below. However, this is meant to give you an overview and may not describe every possible use and disclosure that may occur.
We may use your health information to provide treatment, items and services. For example, we may disclose all or any portion of your health information to the therapists, nurses, doctors and other health care professionals who have a need for such information in order to provide your treatment and care. Access to and disclosure of your health information will be based on a “minimum necessary” rule. The “minimum necessary” will be determined by the function of the staff member requesting information, the sensitivity of the information being requested and a decision regarding whether that information is essential for that staff member to complete their duties.
We may use and disclose your health information so that we may bill and receive payment for treatment and services that you receive. Your information may also be necessary to determine coverage, medical necessity, pre-authorization or certification. The information may be disclosed to an insurance company, third party payer or other entity, (or their authorized representatives) involved in the payment of your medical bill and may include copies or portions of your rehabilitation and medical record, which are necessary for payment of your account.
Health Care Operations
We may use and disclose your health information for our health care operations, including quality assurance, utilization review, medical review, internal auditing, accreditation, social services certification, licensing or credentialing activities and educational purposes.
Other Health Care Providers, Health Plans, and Clearinghouses:
Activities of Organized Health Care Arrangements
For certain activities, the various components of UI/TR and other independent providers are called an Organized Health Care Arrangement. We may disclose information about you to health care providers participating in our Organized Health Care Arrangements as necessary to carry out our treatment, payment, or health care operations. All participants in our Organized Health Care Arrangement have agreed to abide by the terms of this Notice with respect to your health care information created or received as part of the delivery of health care services to you at UI/TR.
We may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care.
Persons Involved in your Care
Unless you object, we may disclose your health information to family members, other relatives, close personal friends, or any other person(s) who are involved with your medical care or payment.
Unless you object, we may use or disclose your health information to a public or private entity authorized by law or by charter to assist in disaster relief efforts including notifying your family about your condition, status and location.
Health Related Benefits and Services
We may use and disclose your health information to tell you of health-related benefits or services that may be of interest to you.
We may use and disclose health information to business associates. A business associate is an individual or entity under contract with us to perform or assist UI/TR in a function or activity which requires the use or disclosure of health information. Examples of business associates are accountants and lawyers.
We may use or disclose health information about you if we remove all information that could be used to identify you, i.e. “de-identified” data. We are required to remove eighteen (18) different pieces of information that could be used to possibly identify you.
Health Oversight Agencies
We may use and disclose your health information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary for the government and other certain private health oversight agencies to monitor the healthcare system, government programs, and compliance with civil rights.
We may use and disclose your health information for law enforcement purposes to a law enforcement official if required by law, or where permitted by law, or in response to a valid subpoena. Also, we may disclose health information if it is necessary for law enforcement authorities to identify or locate an individual.
Disclosures in Judicial / Legal Proceedings
We may use and disclose your health information to a court or administrative agency when a judge or administrative agency orders us to do so. We may also use and disclose information about you in legal proceedings, such as in a response to a discovery request, subpoena, court order, etc. Also, UI/TR may use or disclose your health information in preparation for any dispute or litigation between you and UI/TR.
Public Health Risk
We may use and disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. For example, we may be required by law to report the existence of a communicable disease to the State Department of Health to protect the health and wellbeing of the general public. Other activities generally disclosed include the following:
To prevent or control disease, injury or disability
To report births or deaths
To report child abuse or neglect
To report reactions to medications or problems with products
To notify a person who may have been exposed to a communicable disease or may be at risk for contacting or spreading a disease or condition
To notify the appropriate government authority if UI/TR believes a patient has been the victim of abuse, neglect, domestic violence or exploitation
Safety of a Person or the Public
We may use and disclose your health information to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
We may use and disclose health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
We may use and disclose your health information as required by military command authorities, if you are a member of the armed forces.
If you are an inmate of a correctional institution or under the custody of a law enforcement officer, we may release your medical record information to the correctional institution or law enforcement official.
Required by Law
We may use and disclose health information about you when required to do so by state or federal law.
National Security and Intelligence Activities
We may use and disclose your medical information about you to authorized federal officials for intelligence, counterintelligence, and other National Security activities as authorized by law. We may also disclose health information about you to authorized federal officials so they may provide protection to the President or other authorized persons.
Coroners, Medical Examiners, Funeral Directors
We may release your health information to a coroner or medical examiner. This may be necessary, for example, to determine a cause of death, UI/TR may also release your health information to funeral directors as necessary to carry out their duties.
Secretary of the Department of Health and Human Services
We may use and disclose your health information when required by the Secretary of Health and the Department of Health and Human Services for purposes of investigation or determining compliance with the privacy law.
Other Uses That Require Providing You the Opportunity to Agree or Object:
Others Involved in Your Health Care or Payment for Your Care
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure we may disclose such information as necessary if we determine that it is in your best interest based on professional judgment. We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative or any other person who is responsible for your care of your location, general condition or death. We may also use or disclose your information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Other Uses and Disclosures Based Upon Your Written Authorization
Any other uses and disclosures of your health information will be made only with your written authorization, unless otherwise permitted or required by law as described above. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
We may not disclose your psychotherapy notes without your specific written authorization.
We may not use or disclose your health information for marketing purposes, without your written authorization.
Sale of PHI
Any uses or disclosures that constitute the sale of protected health information must have your written authorization.
At your request we may post a paper copy of your schedule in a rehabilitation area for you to reference. With your signed authorization we may have client workers review the main schedule and prepare a weekly typed copy of your schedule to post for your reference.
Right to Access Personal Health Information
You have the right to inspect and/or obtain a copy of your PHI in a designated record set for as long as the PHI is maintained except for:
Information compiled in reasonable anticipation of, or use in a civil, criminal or administrative action or proceeding.
UI/TR will provide access to the requested PHI in any reasonable format requested by the individual;
Access will be provided within thirty (30) days;
A reasonable fee may be charged for copies of PHI.
Unreviewable Grounds for Denial – UI/TR may deny an individual access without providing an opportunity for review if:
The PHI requested are psychotherapy notes;
The information was compiled in reasonable anticipation of, or use in a civil, criminal or administrative proceeding;
Access may be denied if the PHI requested was obtained from someone other than a health care provider under the promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.
Reviewable Grounds for Denial – UI/TR may deny access to PHI provided the individual is given the right to have such a denial reviewed in the following circumstances:
A licensed health care professional has determined, in the exercise of professional judgment, that the access required is reasonably likely to endanger the life of the individual or another person;
The PHI makes reference to another client or a witness to an act and a licensed health care professional has determined the access requested is reasonably likely to cause substantial harm to the individual or another person;
The request for access is made by the legal guardian and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to the legal guardian is reasonably likely to cause substantial harm to the individual or another person.
Access denied – if access is denied, UI/TR must provide a timely written denial . The denial must be in plain language and contain:
The basis for the denial;
Statements of the individuals review rights and how the individual may exercise their rights, and
A copy of the Complaint Form.
If UI/TR does not maintain the requested PHI, then the denial must inform the individual where to direct the request, if known.
If the individual appeals the denial then the appeal must be reviewed by a licensed health care professional who was not involved in the original decision to deny access.
UI/TR must document all actions covered in the requests for access and denial of access.
Right to Accounting of Disclosures
You may request an accounting of disclosures other than for treatment, payment or health care operations.
An accounting will exclude disclosures we have made to you and to persons involved in your care.
A client/guardian has the right to receive an accounting of disclosures that occur after April 14, 2003.
The first accounting requested within a 12 month period will be free of charge. For additional requests a reasonable fee may be charged.
UI/TR will notify you of the cost involved so you have the opportunity to withdraw or modify the request.
Right to Request Restrictions
You have the right to request a restriction or limitation on the PHI that UI/TR uses or discloses for treatment, payment or general operations. You also have the right to request a restriction or limitation on the PHI disclosed to a family member or someone who is involved in your payment or care.
Requests must be made in writing to the Privacy Officer.
The request must indicate the information to be limited; whether the use, disclosure or both are limited and to whom the limits apply.
UI/TR has the right to disagree with and deny any request it determines is needed for treatment, payment or general health care operations. A denial for any other reason will be put in writing and a response will be made within 30 days of the request.
If UI/TR agrees, then the request will be complied with except in the case of an emergency.
We may not deny your request to restrict disclosure of your health information to your health insurance plan for services which you paid for in full out of pocket.
Right to Request Amendments
You have the right to request an amendment to the PHI in a designated record set.
The request must be made in writing to the Privacy Officer.
UI/TR must notify you if the request is accepted or denied within thirty days of the request.
UI/TR may deny the request if
It is not in writing;
There is no reason given for the request;
The record was not created by UI/TR;
The record is not part of the medical record maintained by UI/TR;
The record is not part of the information that may be reviewed or copied by the individual, or
The record is complete and accurate.
Accepting the amendment – if UI/TR accepts the amendment, then,
Universal must make the appropriate amendment to the PHI by identifying the records that are affected by the amendment and appending them or at least providing a link to the amended information;
UI/TR must inform the individual of the acceptance and obtain the individuals identification of and agreement to have Universal notify the relevant parties with which the amended information needs to be shared;
UI/TR must make reasonable efforts to inform and provide the amendment within reasonable time to persons identified by the individual as needing the information and persons including business associates that Ul/TR knows have the PHI that has been amended and that may have relied or could reasonably rely on the information to the detriment of the individual.
Denying the amendment- if UI/TR denies the requested amendment, in whole or in part, a written notice of denial must be provided to you within thirty days. The denial must contain:
The basis for the denial;
Your right to submit a statement of disagreement with the denial;
A statement that, if the individual does not submit a disagreement statement, the individual may request that UI/TR provide the individuals request for amendment and the denial with any future disclosures of PHI that is the subject of the requested amendment, and
A description of how the individual may file a complaint. The description must include the name, title and phone number of the Privacy Officer.
Statement of Disagreement – UI/TR must permit the individual to submit a written statement disagreeing with the denial, in whole or any part, of the requested amendment and the basis of such disagreement. UI/TR may reasonably limit the length of the disagreement statement. If a statement of disagreement is submitted, UI/TR must include the material appended, or an accurate summary of any such information, with any subsequent disclosure of the PHI to which the disagreement relates.
Rebuttal Statement – UI/TR has the right to prepare a written rebuttal to the individual’s disagreement statement. Whenever such a rebuttal is prepared UI/TR must submit a copy of the rebuttal to the individual who submitted the statement of disagreement.
Right to Request Confidential Communication
A client or guardian has the right to request that UI/TR communicate about PHI in a certain way or at a certain location. All such requests must be made in writing to the Privacy Officer. UI/TR will comply with all reasonable requests.
Right to File a Complaint
You have the right to file a complaint if you believe your privacy rights have been violated. The complaint must
i. be filed in writing
ii. be submitted to the Privacy Officer
UI/TR must respond to the complaint within thirty days.
The complaint must be filed within 180 days of when the complainant knew that the act or omission complained of occurred.
Complaints may also be filed with the Office of Civil Rights.
Right to be Notified of a Breach
You have the right to be notified in the event that UI/TR discovers a breach of unsecured protected health information.