Neurology New Patient Welcome Packet - Mount Sinai Hospital

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Your written authorization is obtained;The disclosure is allowed by a court order and permitted under Federal and Stateconfidentiality laws and regulations;The disclosure is made to medical personnel in a medical emergency;The disclosure is made to qualified researchers without your written authorizationwhen such research poses minimal risk to your privacy. When required by law,we will obtain an agreement from the researcher to protect the privacy andconfidentiality of your information;The disclosure is made to a qualified service organization that performs certaintreatment services (such as lab analyses) or business operations (such as billcollection) for Mount Sinai. Mount Sinai will obtain the qualified serviceorganization’s agreement in writing to protect the privacy and confidentiality ofyour information in accordance with Federal and State law;The disclosure is made to a government agency or other qualified nongovernmentpersonnel to perform an audit or evaluation of Mount Sinai. MountSinai will obtain an agreement in writing from any non-government personnel toprotect the privacy and confidentiality of your information in accordance withFederal and State law;The disclosure is made to report a crime committed by a patient either at MountSinai or against any person who works for Mount Sinai or about any threat tocommit such a crime; orThe disclosure is made to report child abuse or neglect to appropriate State orLocal authorities.Violation of these privacy regulations is a crime. Suspected violations may be reported toappropriate authorities in accordance with Federal and State law.Please refer to Mount Sinai's main Notice of Privacy Practices for additional information.MR-250 (Rev 5/04)15
MOUNT SINAIATTACHMENT CCONFIDENTIALITY OF MENTAL HEALTH INFORMATIONAND PSYCHOTHERAPY NOTESEffective Date: April 14, 2003The privacy and confidentiality of mental health information and psychotherapy notesmaintained by Mount Sinai is protected by Federal and State law and regulations. Theseprotections go above and beyond the protections described in the Mount Sinai Notice of PrivacyPractices. If you have questions about this notice or would like further information, pleasecontact:The Mount Sinai Hospital and Diagnostic and Treatment Center Privacy Officer at (212)241-4669The Mount Sinai School of Medicine FPA Patient Rights Coordinator at (212) 241-7715The Mount Sinai Hospital of Queens Privacy Officer at (718) 267-4220Northshore Medical Group Privacy Officer at (631) 367-5125We recommend that you also take time to review the Mount Sinai Notice of Privacy Practices forinformation about how your health information may generally be used and disclosed by MountSinai. The Notice of Privacy Practices also provides information about how you may obtainaccess to your health information, including mental health information. If there is any conflictbetween the Notice of Privacy Practices and this notice, the protections described in this noticewill apply instead of the protections described in the Notice of Privacy Practices.CONFIDENTIALITY OF MENTAL HEALTH INFORMATIONMental health information about you may be used by personnel within Mount Sinai (or itsBusiness Associates) in connection with their duties to provide you with treatment, obtainpayment for that treatment, or conduct Mount Sinai’s business operations. Generally MountSinai may not reveal mental health information about you to other persons outside of MountSinai, except in the following situations:When Mount Sinai has obtained your written authorization;To a personal representative who is authorized to make health care decisions on yourbehalf;To government agencies or private insurance companies in order to obtain payment forservices we provided to you;To comply with a court order;To appropriate persons who are able to avert a serious and imminent threat to the healthor safety of you or another person;MR-250 (Rev 5/04)16
Page 1 and 2: Department of Neurology New Patient
Page 3 and 4: IN CASE OF EMERGENCYPlease notify i
Page 5 and 6: ACKNOWLEDGEMENT OF RECEIPT OF NOTIC
Page 7 and 8: MOUNT SINAI USE OF INFORMATION AUTH
Page 9 and 10: Do'you'have'a'history'of'alcohol'us
Page 11 and 12: PARTICIPANTSMount Sinai provides he
Page 13 and 14: Right To Amend RecordsIf you believ
Page 15 and 16: Right To Request Confidential Commu
Page 17 and 18: Appointment Reminders, Treatment Al
Page 19 and 20: To Avert A Serious And Imminent Thr
Page 21 and 22: Attachment ACONFIDENTIALITY OF HIV-
Page 23: MOUNT SINAIATTACHMENT BCONFIDENTIAL
Page 27 and 28: The mental health professional who
Page 29: NOPPATTACHMENT E“Mount Sinai Off-

Neurology New Patient Welcome Packet - Mount Sinai Hospital

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