C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right to request that we place
additional restrictions on our use or disclosure of your health information for treatment, payment and healthcare
operation purposes. Depending on the circumstances of your request we may, or may not, agree to those restrictions.
If we do agree to your requested restrictions, we must honor them except in emergency treatment situations. You
have the right to request that we communicate with you about your health information by other means or to another
location (e.g., at your place of business rather than at you home). Such requests must be made in writing, must
specify the other means or location and must provide satisfactory explanation how payments will be handled under
the other means or location you request.
D. AMENDMENTS TO RECORDS: We make every effort to maintain complete, accurate and up-to-date
information about you and about your health status. If you believe that our information is incomplete or incorrect,
you have the right to request that we make changes to your health information. Such requests must be made in
writing and must explain why the information should be changed. We may deny you request under certain
circumstances. If you wish to make a change, please contact our Director of Health Information Services at (518)
243-4604.
III. PROTECTION OF YOUR INFORMATION:
We maintain security over your personal information through a combination of physical, electronic and procedural
means as well as contractual arrangements. Through procedures and security levels, we limit access to patient
information to only those employees and others who must use it in order to properly serve your healthcare needs.
IV. EFFECTIVE DATE AND CHANGES TO NOTICE:
We are required to provide you with this notice and to follow the privacy practices described above while this Notice
is in effect. This Notice if effective as of April 14, 2003, and will remain in effect until we replace it. We reserve the
right to change this Notice and the privacy practices described at any time in accordance with applicable law. Before
making significant changes to our privacy practices, we will alter this Notice to reflect the changes and make the
revised Notice available to you upon your request. Any changes we make to our privacy practices and/or to this
Notice may apply to health information created or received by us before the date of the changes.
V. QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concern, please contact us.
If you are concerned that we may have violated your privacy rights or if you disagree with a decision that we made or
any decisions that we may make regarding the use, disclosure or access to your health information, you may complain
to us using the contact information listed below. You also my submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address to file such a complaint upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to
file a complaint with us or with the U.S. Department of Health and Human Services.
Please direct any of your questions or complaints to:
Privacy Officer at (518) 243-4604, Ellis Hospital, 1101 Nott Street, Schenectady, NY 12308.
Telephone: (518) 243-4604
Fax: (518) 243-4078
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