Community Health Initiatives is a not-for-profit outpatient program licensed by the New York State Department of Health as an Article 28 Diagnostic & Treatment Center and designated as a Federally Qualified Health Center. In addition to providing the highest quality services for individuals of all ages, CHI is equally committed to providing these services in a culturally and linguistically appropriate setting emphasizing respect for all.

This packet provides important information about CHI and your rights as a patient of our health center. We suggest that you save it for future reference.

Our Philosophy - It is CHI’s belief that health is not merely the absence of illness. The clinicians at CHI therefore emphasize prevention and wellness in the delivery of primary care medical and ancillary services.

CHI can serve as your medical home offering a full range of preventive care as well as diagnostic and treatment services. All services are delivered in an atmosphere of caring, compassion and patience. Our clinicians are well trained and highly skilled professionals who are responsive, welcoming and committed to providing the highest quality services possible.

Services Provided: Community Health Initiatives provides the following services onsite:

• General Primary Medical Care
• Screenings
• Well Child Services
• Gynecological Care
• Prenatal and Postpartum Care
• Mental Health Services
• Substance Use Services
• Physical Therapy
• Podiatry
• Psychiatry
• Gastroenterology
• Rheumatology
• Weight Management

CHI providers have admitting privileges at the area’s top hospitals and relationships with high quality specialists throughout the city. If you need a service that we don’t provide, it can be arranged for you and delivered in a coordinated manner to promote efficiency and to minimize duplication of services.

CHI currently accepts Medicaid and Medicare and many major carriers. A list of the plans that we participate in is posted in the waiting room and is updated regularly. If you participate in a plan that we do not take and want to be seen at CHI we will provide you our Sliding Fee Program.

Sliding Fee/Reduced Payment Program: CHI serves all without regard to insurance status and has implemented a sliding fee discount program based on family size and income. If you would like more information about the reduced fee program and to see if you qualify please speak to our front desk staff.

Your Rights as a CHI patient: As a patient served by organization that is licensed by the New York State Department of Health you have a number of important rights guaranteed by the state. A copy of the Patient Bill of Rights is attached to this letter and is also posted in our waiting room.

Confidentiality: CHI is committed to keeping your personal health information private to the fullest extent possible. How your information is used and your rights as a patient served by CHI are outlined in our center’s Notice of Privacy Practices which will be made available to you upon registration; which is posted in the waiting room and which will be given to you upon your request.

Advance Directives: The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family member or close friend – to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. If you are interested in learning more about Advance Directives please ask the front desk to provide you with the New York State Department of Health publications on this subject.

The Patient/Provider Partnership: So that we can best serve you we ask that you keep in mind the following responsibilities while being served by CHI

1. To provide the Center with accurate medical information.
2. To ask all questions you may have regarding the treatment provided by the Center.
3. To consent by free will to all procedures.
4. To tell us if you do not understand procedures or instructions.
5. To follow after-care instructions as recommended by the Center.
6. To contact your Physician with post-testing questions or concerns.
7. To observe the center’s Policies and Procedures.
8. To keep appointments as scheduled, or advise the Center at least 24 hours in advance if the appointment cannot be kept.
9. To inform us of any changes in your health insurance coverage, address, and contact information.
10. To be considerate of other patients and personnel and respect the property of others and the Center.

Same Day Appointments & After-Hours Call Service: CHI is here to assist you whenever you need us. If you are ill and need to be seen on the same day, we have set aside a number of open slots for same day/walk-in appointments. These are to be used only to address illnesses and are not designed to take the place of regularly scheduled services. CHI has also set up an after-hours answering service if you or a provider need to reach us during days and times that the center is closed. Please call our main number 718-210-3110 and you will be connected to the service. Remember, if you are having a true medical emergency the appropriate course of action is to immediately call 911. Translation service is available for all after hour calls. Please don’t forget to ask to be connected to a translation service.

If you have a Complaint or Grievance: If you have a concern about any aspect of your care while at the center please feel free to speak up and to discuss that concern with any staff member. They can either assist you or direct you to the appropriate party to address your issue. If things cannot be resolved in this manner you can address your concern through our Patient Complaints process. Patient complaints are a written grievance, and should be filed by a patient or the caregiver on behalf of a patient. In order to improve quality of care, patient complaints must be identified and addressed in a timely and efficient manner. Patient complaints will be accepted in writing and will be forwarded to the Chief Operating Officer for investigation and appropriate response. Patient Complaint/Grievance forms are available upon request. You can also fill out a complaint/grievance form on our website at www.chihealthcenter.com, please note this form can be filled out anonymously.

Patient Portal: It is the policy of CHI to provide patients and authorized family members/caregivers with secure two-way electronic communication with practice staff and providers through the Cybermed Patient Portal. Please register for the patient portal with the front desk.

Preventing Child Abuse, Domestic Violence & Human Trafficking: The CHI Health Center is against any form of abuse and/or exploitation. If you feel that you are a victim of any form of abuse, please confide in your provider who will take the necessary steps to assist you. The following telephone numbers may also be helpful to you:

• NYS Child Abuse Central Register 1-800-342-3720
• NYS Domestic Violence Hotline 1-800-942-6906
• National Human Trafficking Hotline 1-888-373-7888

Notice of Deemed Status: This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

In Case of Inclement Weather: While we are committed to keeping the center open for all scheduled hours, there may be times for the safety of our patients and staff that we will need to close due to weather related or other concerns. If we are experiencing severe inclement weather we ask that you please call our main number before leaving home to check if we are open or closed or having a delayed opening. That number is 718-210-3110.

We are here to serve you. If you have a question, concern or suggestion during your time at CHI we hope that you will give us an opportunity to address it by calling it to the attention of our supervisors and/or administrative staff.

Attachments Requiring Patient Review and/or Signature:

• Patient Registration Form
• NYS Patient Bill of Rights (attached document)
• Acknowledgement of Privacy Practices
• General Consent for Treatment
• Patient Portal Consent Form
• CHI Contact Information to be Shown if Hospitalized
• HealthIx Form

CHI Health Center, Inc.

Patient Rights

As a patient at Community Health Initiatives, Inc. you have the following rights. If for any reason you do not understand or need help in interpreting these rights we will provide assistance for you, including an interpreter.

NYS Patients’ Bill of Rights for Diagnostic & Treatment Centers (Clinics)

As a patient in a Clinic in New York State, you have the right, consistent with law, to:

1. Receive service(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, gender identity, national origin or sponsor;
2. Be treated with consideration, respect and dignity including privacy in treatment;
3. Be informed of the services available at the center;
4. Be informed of the provisions for off-hour emergency coverage;
5. Be informed of and receive an estimate of the charges for services, view a list of the health plans and the hospitals that the center participates with; eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care;
6. Receive an itemized copy of his/her account statement, upon request;
7. Obtain from his/her health care practitioner, or the health care practitioner’s delegate, complete and current information concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand;
8. Receive from his/her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision;
9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his/her action;
10. Refuse to participate in experimental research;
11. Voice grievances and recommend changes in policies and services to the center’s staff, the operator and the New York State Department of Health without fear of reprisal;
12. Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health;
13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment;
14. Approve or refuse the release or disclosure of the contents of his/her medical record to any health-care practitioner and/or health-care facility except as required by law or third-party payment contract;
15. Access to his/her medical record per Section 18 of the Public Health Law, and Subpart 50-3. For additional information link to: https://www.health.ny.gov/publications/1449/section_1.htm#access;Access to Your Medical Records and Do I Have the Right to See My Medical Records?
16. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors;
17. When applicable, make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). The health care proxy is available from the center;
18. View a list of the health plans and the hospitals that the center participates with; and
19. Receive an estimate of the amount that you will be billed after services are rendered.

This joint notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please carefully review the information.

Introduction

This Joint Notice is being provided to you on behalf of Community Health Initiatives, Inc, (FQHC) and the employees and practitioners that work at the FQHC with respect to services provided at FQHC collectively referred to herein as “We” or “Our”). We understand that your medical information is private and confidential. Further, we are required by law to maintain the privacy and security of “protected health information.” “Protected health information” or “PHI” includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the FQHC facilities.

As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from the FQHC’s Compliance Officer at the FQHC Facilities or you can access it on our website at www.chihealthcenter.com.

PERMITTED USES AND DISCLOSURES

We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.

• Treatment means the provision, coordination or management of your health care, including consultations between health care providers relating to your care and referrals for health care from one health care provider to another. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to contact a physical therapist to create the exercise regimen appropriate for your treatment.
• Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, determinations of eligibility and coverage and other utilization review activities. For example, we may need to provide PHI to your Third-Party Payor to determine whether the proposed course of treatment will be covered or if necessary to obtain payment. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release, when necessary, under applicable law. Note that genetic information cannot be used to decide whether coverage can be given or at what price.
• Health care operations means the support functions of the FQHC, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. For example, we may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you so that others can use the de-identified information to study health care and health care delivery without learning who you are.

Other Uses and Disclosures of Protected Health Information

We may also use your PHI in the following ways:

• To provide appointment reminders for treatment or medical care.
• To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.
• To your family or friends or any other individual identified by you to the extent directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.
• We may include certain limited PHI in the Hospital directory. This may include your name, location in the Hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. You may request not to be listed in the directory.
• When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.
• We will allow your family and friends to act on your behalf to pick-up filled prescriptions, medical supplies, X-rays, and similar forms of PHI, when we determine, in our professional judgment, that it is in your best interest to make such disclosures.
• We may contact you as part of our fundraising and marketing efforts as permitted by applicable law. You have the right to opt out of receiving such fundraising communications
• We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a patient’s need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.
• We will use or disclose PHI about you when required to do so by applicable law.
• In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified of these disclosures by your employer or the Hospital as required by applicable law.

Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

Special Situations

Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:

• Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.
• Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
• Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.
• Public Health Activities. We may disclose PHI about you for public health activities, including disclosures: * to prevent or control disease, injury or disability; * to report births and deaths; * to report child abuse or neglect; * to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products; * to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; * to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law.
• Health Oversight Activities. We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, and civil rights).
• Judicial and Administrative Proceedings. We may disclose PHI in judicial and administrative proceedings subject to certain limitations.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations.
• Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
• In response to a court order, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime under certain limited circumstances;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct on our premises; or
• In emergency circumstances, to report a crime, the location of a crime or the victims, or the identity, description or location of the person who committed the crime.
• Victims of Abuse, Neglect or Domestic Violence. We may notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence.
• Coroners, Medical Examiners and Funeral Directors. We may release PHI to a coroner or medical examiner. We may also release PHI about patients to funeral directors as necessary to carry out their duties.
• National Security and Intelligence Activities. We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary
• To provide you with health care;
• To protect your health and safety or the health and safety of others; or
• For the safety and security of the correctional institution.
• Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe 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 necessary for law enforcement authorities to identify or apprehend an individual.

Note: HIV related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially protected health information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.

OTHER USES OF YOUR HEALTH INFORMATION

Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures:

• Of psychotherapy notes (where appropriate);
• For marketing purposes; and
• That constitute a sale of PHI under the Privacy Rule

Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

YOUR RIGHTS

• You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.
• You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to the Privacy Officer.
• You have the right to inspect and copy the PHI contained in our Clinical records, except:
  1. for psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling sessions and have been separated from the rest of your medical record);
  2. for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
  3. if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
  4. if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
  5. for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
  6. for PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of the information.

In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Clinical Director. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.

We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

You have the right to request an amendment or correction to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request: was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment; is not part of your medical or billing records or other records used to make decisions about you; is not available for inspection as set forth above; or is accurate and complete.

• In any event, any agreed upon amendment or correction will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment or correction to your PHI, you must submit your request in writing to Clinical Director at the FQHC Facility, along with a description of the reason for your request.
• You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures:
  • to carry out treatment, payment and health care operations as provided above;
  • incidental to a use or disclosure otherwise permitted or required by applicable law;
  • pursuant to your written authorization;
  • for the Hospital’s directory or to persons involved in your care or for other notification purposes as provided by law;
  • for national security or intelligence purposes as provided by law;
  • to correctional institutions or law enforcement officials as provided by law;
  • as part of a limited data set as provided by law.

To request an accounting of disclosures of your PHI, you must submit your request in writing to the Compliance Officer at the FQHC Facility. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve-month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

• You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.

Complaints

If you believe that your privacy rights have been violated, you should immediately contact the FQHC Compliance Officer at 718-210-3110 EXT. 1003 or you can report a compliance concern by clicking the compliance hotline on our website- chihealthcenter.com. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services.

Contact Person

If you have any questions or would like further information about this notice, please contact the FQHC Compliance Officer – Dr. Vainstein at 718-210-3110 EXT. 1003

This notice is effective as of January 02, 2019