As a member of Affinity Health Plan, you have a right to:
• Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation.
• Be told where, when and how to get the services you need from Affinity Health Plan.
• Be told by your PCP what is wrong, what can be done for you, and what will likely be the result in language you understand.
• Get a second opinion about your care.
• Give your OK to any treatment or plan for your care after that plan has been fully explained to you.
• Refuse care and be told what you may risk if you do.
• Get a copy of your medical record, and talk about it with your PCP, and to ask, if needed, that your medical record be amended or corrected.
• Be sure that your medical record is private and will not be shared with anyone except as required by law, contract, or with your approval.
• Use the Affinity Health Plan complaint system to settle any complaints, or you can complain to the New York State Department of Health or the local Department of Social Services any time you feel you were not fairly treated.
• Use the State Fair Hearing system
• Appoint someone (relative, friend, lawyer, etc.) to speak for you if you are unable to speak for yourself about your care and treatment.
• Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints
Your Responsibilities
As a member of Affinity Health Plan, you agree to:
• Work with your PCP to guard and improve your health.
• Find out how your health care system works.
• Listen to your PCP’s advice and ask questions when you are in doubt.
• Call or go back to your PCP if you do not get better, or ask for a second opinion.
• Treat health care staff with the respect you expect yourself.
• Tell us if you have problems with any health care staff. Call Member Services.
• Keep your appointments. If you must cancel, call as soon as you can.
• Use the emergency room only for real emergencies.
• Call your PCP when you need medical care, even if it is after-hours.
Advance Directives
There may come a time when you can’t decide about your own health care. By planning in advance, you can arrange now for your wishes to be carried out. First, let family, friends and your doctor know what kinds of treatment you do or don’t want. Second, you can appoint an adult you trust to make decisions for you. Be sure to talk with your PCP, your family or others close to you so they will know what you want. Third, it is best if you put your thoughts in writing. The documents listed below can help. You do not have to use a lawyer, but you may wish to speak with one about this. You can change your mind and these documents at any time.
We can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can’t speak for yourself.
Health Care Proxy - With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so. If you do this, you should talk with the person so they know what you want.
CPR and DNR - You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. Your PCP will provide a DNR (Do Not Resuscitate) order for your medical records.
You can also get a DNR form to carry with you and/or a bracelet to wear that will let any emergency medical provider know about your wishes.
Organ Donor Card - This wallet sized card says that you are willing to donate parts of your body to help others when you die. Also, check the back of your driver’s license to let others know if and how you want to donate your organs.
Important Phone Numbers
Your PCP ...--- ---- Affinity Health Plan
Customer Service ...1-866-247-5678 Customer Service TTY/TDD ...1-800-662-1220 Your nearest Emergency Room ...--- ----
New York State Department of Health (Complaints) ...1 800-206-8125 ___________ County Department of Social Services ...--- ----
New York Medicaid Choice ...1-800-505-5678 Local Pharmacy ...……… ...--- ----
Other Health Providers:
Block Vision (Eye care) ...1-800-428-8789 Beacon Health Strategies (Behavioral Health) ...1-800-974-6831 HealthPlex (Dental care) ...1-800-468-0608
CVS Caremark (Pharmacy) ...1-855-465-0031
FEDERALLY QUALIFIED HEALTH CENTERS (FQHCs)
Borough
/ County Federally Qualified Health Centers Address City Zip
Code Bronx Bella Vista Health Center 890 Hunts Point Avenue Bronx 10474 Bronx Burnside Medial Center 165 East Burnside Avenue Bronx 10453 Bronx Community Healthcare Network 975 Westchester Avenue Bronx 10459 Bronx Comprehensive Community Dev. Corp. 731 White Plains Road Bronx 10473 Bronx Comprehensive Family Care Center 1621 Eastchester Road Bronx 10461
Bronx Comprehensive Health Care Center 305 East 161st Street Bronx 10451 Bronx Delany Sisters Health Center 2727-33 White Plains Road Bronx 10467
Bronx Diallo Medical Center 1760 Westchester Avenue Bronx 10472
Bronx Family Health Center 360 East 193rd Street Bronx 10458
Bronx Hunts Point Multi-Service Center 661 Cauldwell Avenue Bronx 10455 Bronx Hunts Point Multi-Service Center 1675 Westchester Avenue Bronx 10472 Bronx Jessica Guzman Medical Center 616 Castle Hill Avenue Bronx 10473 Bronx Martin Luther King Jr. Health Center 3674 Third Avenue Bronx 10456 Bronx Morris Heights Health Center 85 West Burnside Avenue Bronx 10453 Bronx Plaza del Castillo Health Center 1515 Southern Blvd Bronx 10460
Bronx Urban Health Plan 1070 Southern Blvd Bronx 10459
Bronx Westchester Avenue Health Center 1990 Westchester Avenue Bronx 10462
Kings Bedford Stuyvesant Family Health Center 1413 Fulton Street Brooklyn 11216 Kings Brownsville Multi-Service Family HC@ Genesis 360 Snediker Ave Brooklyn 11207
Kings CABS Health Center 94-98 Manhattan Avenue Brooklyn 11206 Kings Caribbean House Health Center 1167 Nostrand Avenue Brooklyn 11225 Kings Dr. Betty Shabazz Health Center 999 Blake Avenue Brooklyn 11208 Kings Family Physician Health Center 5616 Sixth Avenue Brooklyn 11220
Kings Park Slope Health Center 220-13th Street Brooklyn 11215
Kings Sunset Park Family Health Center 150 55th Street Brooklyn 11220
New York NENA Health Council 279 E. 3rd Street New York 10009
New York Amsterdam Avenue Healthcare Center 690 Amsterdam Ave New York 10025 New York Charles B. Wang Community Health Center 268 Canal Street New York 10013 New York Charles B. Wang Community Health Center 125 Walker Street 2nd Floor New York 10013 New York Community League Health Center 1996 Amsterdam Ave New York 10025
New York Helen B. Atkinson Health Center 81 West 115th Street New York 10026 New York Heritage Health and Housing , INC 1727 Amsterdam Avenue New York 10031
New York Institute for Urban Family Health, INC 16 East 16th St New York 10003 New York Ryan/Chelsea-Clinton Community Health 645 Tenth Avenue New York 10036
New York William F. Ryan Community Health center 110 West 97th Street New York 10025 New York William F. Ryan Community Health center 160 West 100 Street New York 10025
Queens Charles B. Wang Community Health Center 136-26 37th Avenue Flushing 11354 Queens Damian Family Care Center 137-50 Jamaica Avenue Jamaica 11434 Queens Joseph P. Addabbo Family Health Center 130-20 Farmers Blvd Jamaica 11434
Queens Joseph P. Addabbo Family Health Center 190 Beach 68th Street Arverne 11692 Queens Joseph P. Addabbo Family Health Center 1288 Central Avenue Far Rockaway 11691
Queens Joseph P. Addabbo Family Health Center 67-10 Rockaway Beach Blvd Arverne 11692 Richmond Beacon Christian Community Health Center 2079 Forest Avenue Staten Island 10303 Orange Ezras Choslim Health Center, Inc. 49 Forest Road Monroe 10950 Orange Greater Hudson Valley Family Health Center 3 Washington Center Newburgh 12550
Orange Middletown Community Health Center 135 North Street Middletown 10940 Orange Middletown Community Health Center 10 Benton Avenue Middletown 10940
Orange Middletown Community Health Center 27 North Street Middletown 12566 Orange Middletown Community Health Center 99 Cameron Street Pine Bush 12586
Rockland Ben Gilman Spring Valley Medical & Dental Clinic 175 Rte 59 Spring Valley 10977 Rockland Monsey Family Health Center 40 Robert Pitt Drive Monsey 10952
This Notice describes how medical information about you may be used and disclosed by Affinity Health Plan and how you can get access to this information.
Please read it carefully.
Why Affinity Health Plan Collects Health Information About You
In order to provide you with the benefits to which you are entitled, Affinity Health Plan must collect, create and maintain health information about you. Affinity Health Plan is required by law to maintain the privacy of this information. This Notice of Privacy Practices describes how Affinity Health Plan uses and discloses your health information, and explains certain rights you have regarding this information.
Affinity Health Plan is required by law to provide you with this Notice and we will comply with its terms during the period when it is effective. If you have any questions about our Privacy Policies and Procedures, you may call our toll free number 1-866-247-5678, or write to our Chief Privacy Officer, Affinity Health Plan, 2500 Halsey Street, Bronx, New York 10461.
How Affinity Health Plan Uses and Discloses Your Health Information
The following is a list of the ways in which Affinity Health Plan may use and disclose your health information. We will use and disclose your health information only for one of the purposes on this list. In certain cases, we provide examples of the types of uses or disclosures that fall within a particular category. These examples are intended to help you understand what these categories mean; they do not cover every type of use or disclosure within each category. Please note that, as discussed later in this Notice of Privacy Practices, special rules apply to our disclosure of certain alcohol and drug abuse treatment records.
Uses and Disclosures for Payment and Health Care Operations. After Affinity Health Plan has obtained your general consent to use and disclose your health information to administer your benefits and for other purposes permitted by state or federal law, we may use and disclose your health information for the following purposes:
• Treatment. We may use and disclose health information about you to facilitate treatment by health care providers. For example, if one of our participating health care providers is treating you, we may disclose to this provider health information relating to other health care services you have received that may be relevant to the provider's treatment.
• Payment. We may use and disclose health information about you for our own payment purposes and to assist in the payment activities of other health plans and health care providers. Our payment activities include collecting premiums, determining your eligibility for benefits, reimbursing health care providers that treat you and obtaining payment from other insurers that may be responsible for providing coverage to you. For example, if a health care provider submits a bill to us for services you received, we may use health information about you to determine whether these services are covered under your benefit plan and the appropriate amount of payment to which the provider may be entitled.
• Health Care Operations. We may use and disclose health information about you to carry out health care operations, which includes quality improvement activities, evaluating our own performance and resolving any complaints or grievances you may have. For example, we may collect and review records maintained by doctors and hospitals that have treated you to see
whether they have provided you with preventive treatment and other important health services that are recommended by medical authorities. We may also use and disclose your health information to assist other health plans and health care providers in performing certain health care operations, such as quality assessment and improvement, reviewing the competence and qualifications of health care providers and conducting fraud detection or compliance.
• Appointment Reminders. We may use and disclose your health information to remind you about appointments you have made to receive health care services or to encourage you to make such appointments.
• Treatment Alternatives. We may use and disclose your health information to tell you about treatment alternatives or other health-related benefits and services that may be of interest to you.
Uses and Disclosures Without Your Consent or Authorization. Affinity Health Plan may use and disclose your health information without your specific written authorization for the following purposes:
• As required by law. We may use and disclose your health information as required by state, federal or local law.
• For public health activities. We may disclose your health information to public health authorities or other agencies and organizations conducting public health activities, such as preventing or controlling disease, injury or disability and reporting births, deaths, child abuse or neglect, domestic violence, potential problems with products regulated by the Food and Drug Administration or communicable diseases.
• About victims of abuse, neglect, or domestic violence. We may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect or domestic violence and you agree to the disclosure or the disclosure is required or permitted by law. We will let you know if we disclose your health information for this purpose unless we believe that letting you know would place you at risk of serious harm or we believe that a person who usually receives information from us on your behalf is responsible for the abuse, neglect or domestic violence.
• For health oversight activities. We may disclose your health information to health oversight agencies for oversight activities authorized by law such as audits, investigations, inspections and licensing surveys.
• For judicial and administrative proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an appropriate order of a court or administrative body.
• For law enforcement purposes. We may disclose your health information to a law enforcement official for a legitimate law enforcement purpose such as: identifying or locating a suspect, fugitive or missing person; complying with a court order, subpoena, or administrative request;
providing information about a victim of a crime or reporting a death that may be the result of a crime.
• About deceased individuals. We may disclose your health information to a coroner or medical examiner for purposes such as identifying a deceased person or determining a cause of death. We may also disclose your health information to a funeral director as necessary to assist such a
person in carrying out his or her duties.
• For organ, eye, or tissue donations. We may disclose your health information to organ procurement organizations and similar entities for the purpose of assisting them in organ, eye or tissue donation or transplantation activities, in the event that you need one for your treatment.
• For research. We may use or disclose your health information for research purposes, such as studies comparing the benefits of alternative treatments received by our members or investigations into how to improve our enrollment and education procedures. We will use or disclose your health information for research purposes only with the approval of our privacy board, which must follow a special approval process. Before permitting any use or disclosure of your health information for research purposes, our privacy board will balance the needs of the researchers and the potential value of their research against the protection of your privacy.
• To avert a serious threat to health or safety. We may use or disclose your health information to prevent or lessen a serious and immediate threat to your health or safety or to the health or safety of another person or the general public. We will disclose your health information for this purpose only to someone who may be able to prevent or lessen this type of threat.
• For specialized government functions. We may use or disclose your health information to provide assistance for certain types of government activities. If you are a member of the armed forces of the United States or a foreign country, we may disclose your health information to appropriate military authorities as they deem necessary to carry out military missions. We may also disclose your health information to federal officials for lawful intelligence or national security activities and for the purpose of providing protective services to the President of the United States and other officials. In addition, if you are in the custody of a correctional institution or law enforcement official, we may disclose your health information to that institution or official for certain purposes.
• For workers’ compensation. We may use or disclose your health information as permitted by the laws governing the workers' compensation program or similar programs that provide benefits for work-related injuries or illnesses.
• To individuals involved in your care. We may disclose your health information to a family member, other relative or close personal friend assisting you in receiving or obtaining payment for health care services. We will disclose your health information to these individuals only if you tell us to do this or if we advise you that we will do so and you do not object. We may also disclose your health information to disaster relief organizations such as the Red Cross to assist your family members or friends in locating you or learning about your general condition in the event of a disaster.
Special Treatment of Certain Alcohol and Drug Abuse Records. Health information we may receive about you from federally assisted alcohol or drug treatment programs is subject to special protection under federal law. We will not disclose this information without your express written authorization except:
• to medical personnel who need this information for the purpose of providing you with emergency treatment;
• to the Food and Drug Administration for the purpose of identifying potentially dangerous products;
• for research purposes if approved by our privacy board;
• to authorized persons conducting on-site audits of our records, subject to the requirement that these persons not remove the information from our facilities and agree in writing to safeguard the information; and
• in response to an appropriate court order.
Obtaining Your Authorization for Other Uses and Disclosures. Affinity Health Plan will not use or disclose your health information for any purpose not specified in this Notice of Privacy Practices unless we obtain your express written authorization. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization in providing benefits. The authorization you give for these uses and disclosures is different from the general consent form you sign at the time of enrollment in Affinity Health Plan. While the consent form contains general language allowing us to use and disclose your health information for treatment, payment, health care operations and other purposes permitted by law, the authorization form more specifically describes the purpose of the use or disclosure, the nature of the information that will be used or disclosed and the persons or groups of
Obtaining Your Authorization for Other Uses and Disclosures. Affinity Health Plan will not use or disclose your health information for any purpose not specified in this Notice of Privacy Practices unless we obtain your express written authorization. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization in providing benefits. The authorization you give for these uses and disclosures is different from the general consent form you sign at the time of enrollment in Affinity Health Plan. While the consent form contains general language allowing us to use and disclose your health information for treatment, payment, health care operations and other purposes permitted by law, the authorization form more specifically describes the purpose of the use or disclosure, the nature of the information that will be used or disclosed and the persons or groups of