NOTICE OF PRIVACY
PRACTICES

WHO WILL FOLLOW THE TERMS OF THIS NOTICE

• All health care professionals, employees/1099, students, volunteers and other personnel from these facilities are authorized to access your medical record.
• Independent health care providers not employed by PETAL PSYCHIATRY who are involved in your care.

OUR COMMITTMENT REGARDING YOUR MEDICAL INFORMATION

We are required by law to:

• Make sure that medical information that identifies you is kept private;
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of this Notice.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose your medical information:

• Treatment. We may use your medical information to provide you with medical treatment or services. We may disclose your medical information to others who are involved in taking care of you. We may share your medical information (such as x-rays, lab work, prescriptions) with another health care provider to deliver, coordinate, or manage your healthcare. For example, a doctor treating you at PETAL PSYCHIATRY for a broken leg may need to know about your diabetes care at another facility because diabetes may slow the healing process, or your primary care provider at another facility may need information about your emergency department visit at PETAL PSYCHIATRY in order to provide follow-up care.
• Health Care Operations. We may use and disclose medical information about you for health system operations. For example, we may use your information to review our treatment and services, to assess the care and services we offer and to educate health care professionals or trainees.
• Business Associates. We may disclose your health information to contractors, agents and other associates who need information to assist us in carrying out our business operations. Our contracts with them require that they protect the privacy of your health information.

PETAL PSYCHIATRY Notice of Privacy Practices

• Appointment Reminders. While providing treatment to you, we may use your health information to contact you (e.g.: by phone or postcard) with a reminder that you have an appointment for treatment or services.
• Health-related Benefits and Treatment Alternatives. We may use and disclose medical information to tell you about or recommend health-related benefits, services or treatment alternatives that may be of interest to you.
• During a disaster (e.g., a flood), medical information may be disclosed to an authorized public or private entity authorized by law or its charter to assist with relief efforts (such as the Red Cross).
• Incidental Disclosures. Disclosures of your information may occur during or as an unavoidable result of otherwise permissible uses or disclosures of your health information. For example, during the course of your treatment, other patients in the area may see or overhear discussion of your health information despite using reasonable safeguards
• Personal Representatives. We may disclose your health information to your personal representative who has authority to act on your behalf under applicable law.
• As Required by Law. We may disclose medical information about you without your authorization when required to do so by federal, state or local law.
• Victims of Abuse or Neglect. We may release your health information to a public health authority authorized to receive reports of abuse or neglect.
• Workers' Compensation. We may release medical information about you to programs that provide benefits for work-related injury or illness.
• Public Health Purposes. We may disclose medical information about you for public health activities related to prevention or control of disease, injury or disability. For example, we report certain communicable diseases to the Department of Health.
• Health Oversight Activities. We may disclose your medical information to health oversight organizations authorized to conduct audits, investigations, and inspections of our facilities.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court or administrative order, subpoena or other lawful process.
• Law Enforcement. We may release health information for law enforcement purposes in limited circumstances.
• To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public.
• Organ and Tissue Donation. We may release medical information to organizations that handle organ, eye or tissue donation and transplantation.

PETAL PSYCHIATRY Notice of Privacy Practices

• Coroners, Medical Examiners and Funeral Directors. We may disclose health information to funeral directors, coroners and medical examiners as permitted by law to carry out their duties.
• Inmates. If you are an inmate of a correctional facility, we may disclose to the institution or agents of the institution health information necessary for your health and the health and safety of other individuals.
• Disclosures to Schools. Student immunization information may be disclosed to a school without written authorization if state law requires the school to have immunization records and the patient or personal representative’s written or oral agreement is documented.
• Military and Veterans. If you are or have been a member of the armed forces, we may release your medical information as required by the Departments of Defense, Transportation or Veterans Affairs.

ELECTRONIC HEALTH CARE RECORDS

Some or all of your medical information may be created and/or stored in an electronic format. When permissible for valid purposes (e.g., providing treatment or billing for services) your health care providers may access your medical information electronically. Other healthcare providers outside PETAL PSYCHIATRY caring for you may also receive access to your electronic health records for purposes outlined above.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Receive Copies. You may ask to inspect and to receive copies of medical information that may be used to make decisions about your care, including your medical and billing records. To inspect or receive copies of your medical information, submit your request in writing to the Health Information Management (Medical Records) Department at the facility keeping your medical information. To inspect or receive copies of your laboratory test results or reports ordered by your physician, you can request directly from PETAL PSYCHIATRY. You may be referred to the Hospital’s Health Information Management Department (Medical Records) to respond to your request. We may charge a fee for the costs of copying, mailing or other supplies associated with your request for copies. You may not be denied a copy if you are unable to pay. You may request an electronic copy of your record and it will be provided in an electronic format if it is readily producible; otherwise, you will be provided with a printed copy. We may deny your request to inspect or receive copies in certain limited circumstances. If your request is denied, you may ask that the denial be reviewed. Another licensed health care professional who we choose will review your request and the denial. The person conducting the review will not be the person who denied your request. You have additional rights to appeal a denial to the New York State Department of Health.

Right to Amend- If you feel your medical information is incorrect or incomplete, you may ask to amend the information for as long as we maintain the information. Your request must be made in writing to Petal Psychiatry, the facility keeping your medical information. You must also provide a reason that supports your request.

We may deny your request if the information:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for us; or is accurate/ complete
• Is not part of the information that you would be permitted to inspect or receive copies; or

If your request to amend your record is denied, you will have the right to have certain information related to your requested amendment included in your records. These rights will be explained to you in the written denial notice. Right to a Listing of Persons Receiving Your Medical Information. You may request an "accounting of disclosures” of medical information released about you.

Accounting of disclosures does not include disclosures made:

• to you or your personal representative;
• with your written authorization;
• for treatment, payment or health care operations;

PETAL PSYCHIATRY Notice of Privacy Practices

• to your family or friends involved in your care or payment for your care;
• incidental to permissible uses or disclosures; or
• about inmates to correctional institutions or law enforcement officers.

To request this list, submit your request in writing to the Health Information Management Department at the facility keeping your medical information. Your request must state a time period, which may not be longer than six years and may not include dates before April 01st, 2026. The first list you request within a 12-month period will be free. We may charge you for the costs of providing

additional lists. We will notify you of the cost involved and you may withdraw or change your request before you are charged any fees.

Right to Request Restrictions

• You have the right to request restrictions on how we use or disclose your health information to treat your condition, collect payment for your treatment or for our health care operations. We are not required to agree to your request. If we do agree, we will fulfill your request unless the information is needed to provide you with emergency treatment. You may direct your written request to the Petal Psychiatry facility keeping your medical record.
• You have the right to restrict disclosure of your medical information to your health plan for payment when you make a written request and pay for the service out-of-pocket in full prior to or at the time of the service, or if you make payment arrangements at the time of the service subject to approval of PETAL PSYCHIATRY that are complied with in a timely manner. We will comply with this restriction unless the disclosure is required by law. Right to Request Confidential Communications. You may request that we communicate with you about medical matters in an alternative way or at an alternative location (for example, you may wish to be contacted at work rather than at home). Your request should be directed to the area that would handle the communication. You do not need to provide a reason for your request. Reasonable requests will be made. Right to Breach Notification. You have the right to be notified of a breach of your unsecured protected health information, with a few limited exceptions. A breach is defined as unauthorized acquisition, access, use or disclosure of protected health information in a manner not permitted, unless there is a low probability that the privacy or security of your protected health information has been compromised. Right to a Paper Copy of this Notice. You may obtain a copy of this Notice at the Petal Psychiatry website, or you may also request a paper copy of this Notice at the location where you receive care.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We may make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The current Notice will be displayed and available to you.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a privacy-related complaint with us, you may call the PETAL PSYCHIATRY at 585-606-3083. All complaints to the Department of Health and Human Services must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us your authorization to use or disclose medical information about you, you may revoke that permission, in writing, at any time. However, we are unable to take back any disclosures we have already made with your permission. Your health information may also be disclosed to the Secretary of Department of Health and Human Services for the purpose of investigating or determining PETAL PSYCHIATRY compliance with HIPAA

If you have any concerns about the uses of your medical information, please feel free to discuss the issues with your health care

providers. If you have questions about this Notice, please call the PETAL PSYCHIATRY st 585-606-3083 and ask for director Brittney Selim, PMHNP-BC.