It is the responsibility of the staff of STIC to ensure that every person we work with knows his or her rights and responsibilities as a consumer. These rights and responsibilities reflect STIC's belief in the Independent Living Philosophy. STIC is also required by law to keep your health information private. This Notice tells how STIC uses and releases your health information. It describes your rights and STIC's responsibilities concerning your health information. All people who work for STIC, volunteers, and interns have received a copy of this notice as part of our Health Insurance Portability and Accountability Act (HIPAA) compliance training. All new staff of STIC will get a copy of this notice at employee orientation and be told how to get more information about this Notice.

It is STIC's Policy and Practice that every consumer:

• Is fully informed of his/her rights and responsibilities as a consumer.
• Is not deprived of any civil or legal right guaranteed to all citizens and/or legal aliens, solely because he/she has a disability.
• Is treated with respect and dignity regardless of race, religion, national origin, creed, age, gender, sexual orientation, ethnic background, veteran status, or disability.
• Is assured respect for his/her cultural identity.
• Is free from physical or psychological abuse.
• Is protected from commercial or other exploitation from STIC staff or others affiliated with the organization.

As a consumer of STIC, you are expected to choose, fully participate in, and direct your own services. STIC will not do anything for you that you are capable of doing yourself, but STIC will assist you to learn the skills needed to pursue your goals. You are free to do whatever you choose with the information and training STIC provides you and you are responsible for the results of your choices.

As a consumer of STIC you have the right to:

• Make choices about your goals and what kinds of services you will use. If you are an adult who does not have a legal guardian, STIC assumes that you will personally direct your services and accept full responsibility for all of your decisions and actions. If you are not an adult or you have a legal guardian, STIC will get as much input from you as possible about your wishes, needs, and plans, but your parent(s) or guardian may make some or all of the final decisions.
• Request which staff you will work with. STIC will do our best to honor such requests if the service you need doesn't require the skills or knowledge of a particular staff member, and if the person you request is available to work with you. Because of legal limits on how many people a Service Coordinator can work with, we cannot guarantee that the Service Coordinator you request will be able to work with you.
• Be treated with respect and dignity and be free from mental and physical abuse.
• Voice grievances, concerns, and suggestions without fear of reprisal.
• Take part in planning your services, and changing any service plans, to the best of your ability.
• Object to any part of your services or a plan of services if you have one, and the right to appeal any decision with which you disagree.
• Attend and take part in any meeting concerning you, your services, or your objections to decisions.

As a disability rights organization, STIC strives to be a model of equal access and reasonable accommodation for both our consumers and staff. Toward this end, we provide the following:

• Physical Access: Our facility, and all of our sponsored events, are accessible to people with all disabilities including mobility and sensory disabilities.
• Communication Access: Upon request we provide sign language interpreters for Deaf consumers as well as materials in alternate formats such as: Braille, large print, tape, or computer diskette. Staff or volunteers will read program/ service related materials to consumers if such accommodation is needed and requested.
• Program Access: STIC will provide services in an alternative manner, such as at an alternate site, if an individual's disability requires such accommodation.

You have the following rights concerning your health information. When we use the word "you" in this notice we also mean your personal representative. Depending on your circumstances and in accordance with state law, this could be your guardian, health care proxy, parent, spouse, or child.

• You have the right to ask for limits on certain uses and releases of your health information. STIC does not always have to agree to the limits that you request. If you would like to limit releases of your information you may send a written or taped request to our office (or in an alternate format if necessary). If the request is written you must use the form we give to you.
• You have the right to get your health information in a way that will keep it confidential and meets your needs (examples: Braille, tape, disk). To request your health information, please send a written or taped request to our office (or in an alternate format if necessary).
• You have the right to see, inspect, and copy your health information. If you want to inspect and copy your health information, you may send a written or taped request to our office (or in an alternate format if necessary). If the request is written you must use the form we give to you. Sometimes, as required by State or Federal Law, you may not be allowed to see your health information. If we deny your request to see your health information, you have the right to request a review of that denial.
• You have a right to ask that STIC change or add to your health information if you believe it is incorrect or incomplete. We may deny your request in some cases, for example, if STIC did not create the record, or if it is accurate and complete. If your request is denied you may write a statement of disagreement and require it to be included with all future releases of your health information. You may send such a request in writing or on tape (or in an alternate format if necessary) to our office. If the request is written you must use the form we give to you.
• You have the right to ask for a list of disclosures of your health information. This means that you may ask us for a list of individuals, agencies, organizations, medical personnel, etc. with whom we shared your health information. You may deliver a written or taped request to our office. If the request is written you must use the form we provide to you. The list will not include uses of information for treatment, payment, or operations, disclosures made to you or made to others on your behalf, in accordance with State or Federal Law.
• Usually, but not always, you have the right to be told about certain uses or disclosures of information and you have the right to agree or object to these uses or disclosures. You will be told of disclosures made to family members or friends who are involved in your services, and those made for disaster relief purposes. You will be able to agree or object to these disclosures except in the case of an emergency.
• You have the right to get a paper (tape or computer disk) copy of this Notice at any time. To ask for a copy of this Notice, please contact the staff member working with you or our Compliance Officer. You may also obtain a copy of this Notice on our web site - www.stic-cil.org.
• You may exercise any of your rights by communicating in the way that works best for you. Feel free to communicate in the format of your choice (example: a tape-recorded request).
• STIC will never limit your rights as described in this notice as retaliation for making a complaint, or for the convenience of staff.

If you get services from STIC under the authority of another agency, they may require that STIC refer you to them in order to exercise your rights regarding health information. STIC will do so and you must follow the policies and procedures of that agency. The policies and procedures of that agency may be different from those of STIC. If this does happen a staff member will tell you and refer you to such agency.

STIC may use or disclose health information without your permission for purposes described below. For each category of uses and disclosures, we will explain what we mean and give an example. Not every possible use or disclosure is listed. However, all the ways that we are allowed to use and disclose information will fall within one of the categories.

• Treatment: We may use and disclose your protected health information to provide you with treatment or services. For example, we may give your health information to Service Coordinators, Job Coaches, interns, or volunteers who are involved in providing you with service. We may also give your health information to other organizations that are also providing services to you so they have the information that they need to serve you.
• Payment Functions: We may use or disclose health information about you to collect payment for the services you receive, and to coordinate benefits. For example, we may give information about you to Medicaid so they will pay us for services we provided to you.
• Health Care Operations: We may use and disclose health information when necessary to operate STIC's programs and make sure all consumers receive quality service. For example, we may use information for quality assessment and improvement activities, legal services, audit services, and fraud and abuse detection programs. We may also give your health information to our business partners who need it to perform services on our behalf.
• Required by Law: We may use and disclose your health information as required by State or Federal law.
• Public Health: We may give your health information to public health authorities to: prevent or control disease, report injury or disability, report child abuse or neglect and domestic violence, report reactions to medications, and report birth or death.
• Health Oversight Activities: We may give your health information to health oversight agencies during audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system. These kinds of activities are necessary for government agencies to make sure that we are doing what they pay us for, properly and according to the law.
• Judicial and Administrative Proceedings: We may disclose your health information in the course of any court or administrative proceeding, including hearings and disputes.
• Law Enforcement: We may give your health information to a law enforcement official for purposes such as identifying a suspect, witness, and missing person, or to comply with a court order or subpoena, and other law enforcement purposes.
• Coroners, Medical Examiners, and Funeral Directors: We may give your health information to coroners, medical examiners, and funeral directors. For example, this may be necessary to identify a deceased person or determine the cause of death.
• Organ and Tissue Donation: We may give your health information to organizations involved in banking or transplanting organs and tissues, as necessary.
• Public Safety: We may disclose your health information to prevent or lessen a serious and immediate threat to the health or safety of a particular person or the public.
• National Security: We may disclose your health information for military, or national security purposes.
• Correctional Institutions: we may disclose your health information if you are a prisoner, and the information is necessary to provide you with services.
• Government Agencies: We may give your information to government agencies that administer public benefits (examples: Medicaid, DSS).
• Workers Compensation: We may disclose your health information as necessary to comply with workers compensation or similar laws.
• Appointment Reminders: We may contact you for appointment reminders, service alternatives, or other health related benefits, and unless you request otherwise, we may leave messages about these things on your answering machine or with the person who answers the phone when we call.
• Fundraising: We may contact you for fundraising activities. STIC is a not for profit agency that relies on the support of the community and we may contact you to ask for a donation. Donations are voluntary and there is no obligation for you to make a donation to STIC.
When We May Not Use or Disclose Your Health Information

Except as described above, we will not use or disclose (release) your health information without a written authorization. You may revoke (take back) your authorization in writing if possible (or in an alternate format if necessary), at any time. If you take back or cancel your authorization, we will no longer use or disclose health information about you for the reasons covered by your authorization. Of course, if we have already disclosed your information, with your permission, when you cancel your authorization, we cannot take your information back from those who received it from us. We must keep information about the services that we have provided to you.

To Request Information, Exercise Your Rights, File a Complaint

If you want to exercise your rights, get a better explanation of your rights, or if you want to file a complaint, please contact our Compliance Officer:

Jennifer Donahue
24 Prospect Avenue
Binghamton, NY 13901
(607) 724-2111 V&TTY

If you have a concern about the actions of a staff member that does not relate to misuse of your health information, please contact our Executive Director:

Maria Dibble
24 Prospect Avenue
Binghamton, NY 13901
(607) 724-2111 V&TTY

Before you file a formal complaint with the Compliance Officer or Executive Director, please communicate with the staff member who you are concerned about and give them a chance to resolve your complaint. If the staff member is abusing you in any way, we will understand if you skip this step.

If you are unsatisfied with the staff's response, you may file a written or taped complaint with the Compliance Officer or the Executive Director. If the Executive Director is on vacation, your complaint will go to the Program and Services Coordinator. A written and/or taped decision will be sent to you within ten days.

If you are unsatisfied with the Compliance Officer's and/or the Executive Director's decision, a formal written or taped complaint may be made to Southern Tier Independence Center's President of the Board of Directors. You will receive a written or taped response within ten working days.

If you are still unsatisfied, you may contact the governmental agency you are receiving services under to file an additional complaint. Please refer to the contact list below for contact information.

Department of Health and Human Services

If you believe your health information privacy has been violated, you may also file a written complaint by mailing it or e-mailing it to the Secretary of Health and Human Services located at:

The US Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201
(202) 619-0257
Toll Free: 1-877-696-6775
HHS.Mail@hhs.gov
• STIC cannot, and will not, require you to give up the right to file a complaint with the Secretary of Health and Human Services (HHS) in order to get services from our organization.
• STIC cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Changes to this Notice of Privacy Policy and Consumer Rights

STIC reserves the right to change this Notice at any time and to make the new notice terms effective for all health information that we already have. We will distribute the new notice to you whenever we make important changes. Until such time, STIC is required by law to comply with the current version of this Notice.

CONTACT INFORMATION

STIC

Maria Dibble
Executive Director

Susan Ruff
Job Connections Coordinator

Jo Anne Novicky
Service Coordination Supervisor

Joy Earthdancer
CDPAP Director

Rhonda Bennett / Beth Hall (RRDS)
DOH TBI Program

Jennifer Donahue
Compliance Officer

OMRDD

Patricia McDonnell
Director of Broome DDSO
249 Glenwood Rd.
Binghamton, NY 13905

Thomas Maul
Commissioner of OMRDD
44 Holland Ave.
Albany, NY 12229
(518) 473-9689

Commissioner Gary O'Brien
Commission on Quality of Care
99 Washington Ave. Suite 1002
Albany, NY 12210
(518) 473-4090

CASA

Diane LeFever
HIPAA Privacy Officer
Broome County CASA
PO Box 1766
Binghamton, NY 13902

CAP

Resource Ctr. for Independent Living
409 Columbia Street
Utica, NY 13502
(315) 797-4642
(315) 797-5837 (TTY)

DOH TBI Program

Patricia Green Gumson (RRDS)
NYS Department of Health
Bureau of Long Term Care
TBI Program
One Commerce Plaza, Room 724
Albany, NY 12260
(518) 474-6580

Bruce Rosen (Waiver)
NYS Department of Health
Bureau of Long Term Care
TBI Program
One Commerce Plaza, Room 724
Albany, NY 12260
(518) 474-6580

VESID

Richard Bohman
Director of VESID
44 Hawley Street
Binghamton, NY 13901-4470
(607) 721-8400
(607) 721-8408 (TTY)

Becky Cort
Deputy Commissioner of VESID
NYS Ed. Dept. VESID
One Commerce Plaza, Room 1624
Albany, New York 12234
(800) 222-5627

TASAP

Lorraine Collingwood
231 Main St.
Owego, NY 13832
(607) 687-8550