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Notice of Privacy Practices

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Middletown Medical P.C is dedicated to protecting the privacy of our patients.


Our Obligation to You

We are required by law to maintain the privacy of your “Protected Health Information” (“PHI”), to notify you of our legal duties and your legal rights, and to follow the privacy policies described in this notice, and to abide by the terms of any Notice of Privacy Practices currently in effect.

“Protected health information” means any information, whether written, electronic, or oral, including demographic data, that relates to:

  • Your past, present or future physical or mental health or condition;
  • The provision of health care to you; or
  • The past, present, or future payment for the provision of health care services to you;

And that identifies you or for which there is a reasonable basis to believe it can be used to identify you.

We are required to provide you with a copy of this notice   


Use and Disclosure of Information about You   


Middletown Medical P.C. may use and disclose your PHI, without your authorization, for purposes of treatment, payment, and health care operations (TPO).  

We will use your protected health information and disclose it to others as necessary to provide treatment to you

  • It may be necessary to send blood or tissue samples to a laboratory for analysis to help us evaluate your medical condition.  
  • We may provide information to your health plan or another treatment provider in order to arrange for a referral or clinical consultation.  
  • We will contact you to remind you of appointments, treatment alternatives, and other health related benefits and services.  
  • We may contact you to tell you about treatment services that we offer that might be of benefit to you
  • Various members of our staff may see your clinical record in the course of our care for you. This includes physicians, nurses, medical assistants and other providers.  

We will use or disclose your protected health information as needed to arrange for payment for service to you.  For example, information about your diagnosis and the service we render is included in the bills that we submit to your health insurance plan.  Your health plan may require health information in order to confirm that the service rendered is covered by your benefit program and medically necessary.  A health care provider that delivers service to you, such as a clinical laboratory, may need information about you in order to arrange for payment for its services.  

It may also be necessary to use or disclose protected health information for our health care operations or those of another organization that has a relationship with you.  For example, our quality assurance staff reviews records to be sure that we deliver appropriate treatment of high quality.  Your health plan may wish to review your records to be sure that we meet national standards for quality of care.

Other Uses and Disclosures that do not require your authorization

Emergencies We may disclose your PHI in emergency situations or to avert serious health and safety situations.

Disclosure to your family and friends. If you are an adult, and in the case of certain minors, you have the right to control disclosure of information about you to any other person, including family members or friends.  If you ask us to keep your information confidential, we will respect your wishes.  But if you don’t object, we will share information with family members or friends involved in your care as needed to enable them to help you.

Legally Required. We will disclose your PHI when we are legally required to do so by any federal, state or local law including in judicial settings and to health oversight regulatory agencies and law enforcement.

Abuse or Neglect.  We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others, and as permitted by applicable law.

Public Health Responsibilities.  We will disclose your health care information to the extent required by law to report problems with products, reactions to medications, product recalls, and disease/infection exposure and to prevent and control disease, injury and/or disability.

Appointment Reminders.  We may use your health records to remind you of recommended services, treatment or scheduled appointments.

Research. We may use or disclose your PHI for research when the use or disclosure for research has been approved by an Institutional Review Board or privacy board.

Specified Government Functions. In certain circumstances, federal regulations authorize us to use or disclose your PHI to facilitate specified government functions relating to military and veterans affairs, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions and law enforcement custodial situations.

Workers Compensation. We may release your PHI to comply with workers compensation laws or similar programs.

Fundraising. We may also use or disclose your PHI to contact you about fundraising for ourselves. If you do not wish to be contacted about fundraising, please notify our Contact Person.

Uses or Disclosures that do require your authorization:

We are required to obtain your written authorization prior to the use or disclosure of psychotherapy notes unless such notes are required for purposes as stated above, or as otherwise allowable by law.

We are required to obtain your written authorization prior to the use or disclosure of your PHI for marketing or sale purposes, or any other purposes not referenced in this Notice of Privacy Practices.

You may revoke any prior written authorization you have previously provided to us, except to the extent such authorization has been acted upon.

You have the following legal rights regarding your PHI:

Right to request confidential communications.  You may request that communications to you, such as appointment reminders, bills, or explanations of health benefits be made in a confidential manner.  We will accommodate any such request, as long as you provide a means for us to process payment transactions.  

Right to request restrictions on use and disclosure of your information.  You have the right to request restrictions on our use of your protected health information for particular purposes, such as treatment, payment or health care operations, or our disclosure of that information to certain third parties, such as family members or friends who may be involved in your care.  You have a right to restrict certain disclosures of PHI to a health plan if you are paying out-of-pocket for the healthcare item or service. We are not obligated to agree to a requested restriction, but we will consider your request.  

Right to revoke a Consent or Authorization.  You may revoke a written Consent or Authorization for us to use or disclose your protected health information. The revocation will not affect any previous use or disclosure of your information.  

Right to review and copy record.  You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI. A designated record set usually contains medical and billing records but not psychotherapy notes, or information compiled for use in a civil, criminal or administrative action or proceeding, and PHI for which access of otherwise prohibited by law.

We may deny your request to inspect or copy your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have a right to request a review of this decision.

To inspect and copy your PHI, you must submit a written request to the Medical Records Department. We may charge you a fee to cover copying, mailing or other costs incurred by us in complying with your request.

Right to “amend” record.  You have a right to request an amendment of your PHI in a designated record set for as long as we maintain it.  If there is a mistake, a note will be entered in the record to correct the error.  If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal and provide you with a copy. Requests for amendment must be in writing and directed to the Medical Records Department. This information will be included as part of the total record and shared with others if it might affect decisions they make about you.  

Right to an accounting.  You have the right to an accounting of certain disclosures of your PHI to third parties.  This does not include disclosures that you authorize, or disclosures that occur in the context of treatment, payment or health care operations, or disclosures we are permitted to make without your authorization. The request for an accounting of disclosures must be made in writing to the Medical Records Department. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that took place six years prior to the date on which the accounting is requested, unless otherwise required by law.

Right to a paper copy of this Notice.  You have the right to a paper copy of our Notice of Privacy Practices, even if you have already received a copy of the Notice or have agreed to accept this Notice electronically.

Right to Communication. You have the right to request that we communicate with you in certain ways, and we will accommodate reasonable requests.

Right to Notification. You have the right to receive notifications of breaches of your unsecured PHI.

Right to choose someone to act on your behalf. If you have given someone healthcare power of attorney or if someone is your legal guardian or healthcare proxy, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

How to Exercise Your Rights

Questions about our policies and procedures, requests to exercise individual rights, and complaints should be directed to our Compliance Department at  845-342-2567 or via email at



If you have any complaints or concerns about our privacy policies or practices, please submit a Complaint to our Compliance Officer.  If you wish, our Compliance Officer will give you a form that you can use to submit a Complaint.

You can also submit a complaint to the United States Department of Health and Human Services.  Send your complaint to:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019

We will never retaliate against you for filing a complaint.  


Effective Date

This Notice is effective November 1, 2017


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