We are committed to protecting your privacy and that of your records

At the Kelberman Center, we understand that information about you and your family is personal.

Information is shared only when authorized, when is necessary for treatment, or as mandated by State or Federal Law. In accordance with the Health and Insurance Portability and Accountability Act (HIPAA), our privacy commitment to you is:

  • All people involved in your care will protect your privacy and information will be shared only with the persons/organizations that you have authorized to view the information.
  • Protected Health Information (PHI) includes records we keep or create that are related to your health care or treatment. This includes your medical information, treatment plan, name, address, birth date and social security number.

This privacy notice describes how your medical information may be used, disclosed, and how you may access your records. Please review it carefully.

This privacy notice is effective as of April 14, 2003.

 The Kelberman Center Responsibility for Your Health Information

The Kelberman Center is required by law to:

  • Maintain the privacy of your records
  • Give you notice of our legal duties and practices concerning your health information.
  • Follow the rules contained in this notice.
  • Based on our right to revise the privacy notice, the Kelberman Center will inform you of any changes in privacy practice.

Your Health/Clinical Rights

You have the right to:

  • Review your health/clinical records and obtain a copy of the record. Your request to obtain a copy should be put in writing to the program administrator. He or she will provide you with a release form that you must complete. We will respond to your request within ten days.
  • Records that may not be released include: incident reports, investigation reports and information compiled for use in court or administrative hearings.
  • If your request to access information is denied by the program administrator, you may ask for a review of your request for information from other professional staff members not involved with the denial. Denials will be explained in writing.
  • You may request that the Kelberman Center change or amend your health information if you believe it is incorrect or incomplete. However, the Kelberman Center may deny this request if we believe that the information is accurate. Information in reports not created by the Kelberman Center may not be changed. If the amendment is approved, your record will be changed and we will inform others that need to know.
  • You may request that the Kelberman Center limit how we disclose or use your health information, however the Kelberman Center is not legally bound to agree to this restriction.
  • You may request a list of disclosures the Kelberman Center has made of your health information. The list of disclosures will not include disclosures for treatment, payment, or health care operations within the Kelberman Center or disclosures made to yourself. Disclosures will be recorded from 4/13/03. Your request for disclosures may cover a period of six years prior to the request. We will respond to your request within 60 days.
  • You have a right to receive a copy of the Kelberman Center privacy policy.
  • To request any of these rights, please contact the program administrator.

Uses and Disclosures that Require Your Agreement and Authorization

The Kelberman Center may release your health information following notification to you, if you agree:

  • To family members and personal representatives who are involved in your care.
  • To representatives of disaster relief organizations that may need to contact your family in an emergency situation.

The Kelberman Center Uses and Discloses Health Care Information

The Kelberman Center may use and disclose health information without your permission only in the following situations:

  • Treatment and service purposes within the Kelberman Center and to outside health care providers who are part of your care. For example, the Kelberman Center clinicians may discuss your health information with involved the Kelberman Center staff or staff of other organizations who are providing care.
  • The Kelberman Center may provide health information needed to obtain payment for our services. For example, we may provide information to a funder, i.e. Medicaid, Medicare, or to your insurance company.
  • Appointment reminder notifications.
  • The Kelberman Center may disclose information to determine your eligibility or to determine your ability to pay for services provided. Examples of this would be disclosures to the Social Security Administration or to Medicaid.
  • The Kelberman Center may disclose information within organization for administrative operations such as quality assurance activities, health oversight activities, treatment reviews and service reviews.
  • Information in a summary format may be used to describe the scope of agency services for public relations, fund raising and/or grant applications.
  • Information that identifies specific individuals is restricted unless the Kelberman Center receives prior authorization from you.
  • Information may be released when required by federal or state law or when requested by authorized federal officials for intelligence or national security.
  • Information may be released to report possible domestic violence, abuse or neglect.
  • The Kelberman Center may release information for judicial, law enforcement or administrative proceedings.
  • Information may be released to coroners, medical examiners or funeral directors so they may carry out their duties.
  • Workers compensation cases may require the disclosure of health information.
  • The Kelberman Center may disclose health information for research studies only if you have agreed to participate in these studies and the use of your health information has been approved by an institutional review board by the agency conducting the research.
  • To correctional institutions or law enforcement officials if you are an inmate and the information is necessary for your care or health of others.

Uses and Disclosures that Require Your Agreement and Authorization

The Kelberman Center may release your health information following notification to you, if you agree:

  • To family members and personal representatives who are involved in your care.
  • To representatives of disaster relief organizations that may need to contact your family in an emergency situation.

Authorization Required for All Other Uses and Disclosures

For all other types of uses and disclosures not described in this notice, the Kelberman Center will use or disclose health information only with a written authorization signed by you or your authorized personal representative. The disclosure authorization form may be obtained from your program administrator. Written authorization is always required for use/disclosure of psychotherapy notes and for marketing purposes, which identify an individual.

You may revoke your authorization at any time but you must do so in writing. If you revoke your authorization in writing we will no longer use or disclose your information for the reasons stated in the authorization. We cannot retrieve any disclosures made prior to revoking your authorization. We must also retain your health information that indicated the services we have provided to you.

Note: If you cannot give permission due to an emergency, the Kelberman Center may release health information in your best interest.

The Kelberman Center Uses and Discloses Health Care Information

The Kelberman Center may release your health information following notification to you, if you agree:

  • To family members and personal representatives who are involved in your care.
  • To representatives of disaster relief organizations that may need to contact your family in an emergency situation.

Kelberman Center Privacy Officer

Questions or concerns about the Kelberman Center privacy policy, privacy practices, access to health information or this notice may be forwarded to the Privacy Officer at (315) 738-0794, ext. 301. Written correspondence about these policies may be sent to:

Privacy Officer
The Kelberman Center
258 Genesee St.
Utica, NY 13502

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Kelberman Center Hotline at (315) 724-6907 ext. 7006.

Written complaints may be sent to:
Corporate Compliance Officer
The Kelberman Center
258 Genesee St.
Utica, NY 13502

You may contact the Department Of Health And Human Services at (877) 696-6775 or at:
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201

You may file a grievance with the Office of Civil Rights by calling (866) 627-7748 or (866) 788-4989 (TTY), or at the following address:
Office of Civil Rights
Region II
Federal Building
26 Federal Plaza, Room 3312
New York, NY 10278

All complaints made by telephone must be followed with a written complaint. You will NOT be penalized for filing a complaint. All content on this website is the property of the Kelberman Center. All rights reserved.