Daniel T. Williams, M.D.
 Columbia University Medical Center                                           3003 New Hyde Park Rd.
    710 West 168th Street                                                     New Hyde Park, N.Y. 11042
     New York, N.Y. 10032                                                        T# 516-488-3636
 Website:                                                   F# 516-488-7585

                               Notice of Privacy Practices. Revised 2/17/10

        This notice details the federal requirements concerning the use and release of protected
health information as delineated in federal Health Insurance Portability and Accountability Act
(HIPAA) requirements. Please read and review its content carefully.
        The privacy of your medical information is important to us. The federal government has
established privacy requirements (HIPAA) governing protected health information. This
document is meant to inform you as to how your medical information may and may not be used,
and to whom it may be released. A more detailed 13 page version is available on request.
        Ms. Shirley J. Samansky, Compliance Officer, is in charge of privacy matters in our
office. Feel free to speak with her if you have any questions or concerns. (TEL: 516-488-3636)

    Your protected medical information will not be released to any party without your written
permission, except under circumstances defined by law.
    Federal law provides that we may release your medical information, without specific notice
to you under certain circumstances. These circumstances include and are limited to:
    1. When referring you to another physician for further care
    2. When providing information to your insurance carrier in order to secure payment for your
    3. When obtaining preauthorization from your insurance carrier for further treatment or
    4. For quality assurance, risk reduction, and claim management purposes with our medical
        professional liability insurance carrier
    5. When required by law
    6. When required for public health purposes
    7. In the case of a report of child abuse
    8. When required by law and requested by the Department of Health or Office of
        Professional Misconduct
    9. When required for law enforcement purposes
    10. When required by a medical examiner’s office
    11. When permitted by law to a funeral director
    12. When permitted by law for organ donation
    13. When required by military authorities if you are a member of the United States Armed
    14. Secretarial and Billing Staff in our office may be privy to your name and diagnosis code
        in the performance of their jobs. They are also obligated to protect your privacy.

    We may contact you by mail or phone, at your residence to remind you of appointments, or
to provide you with information concerning your treatment. Unless you instruct us otherwise,
we may leave a message for you on voice mail, answering machine or with the person who
answers your phone. If this is not acceptable to you, you may make a request in writing, to direct
us to use an alternative method to contact you when necessary.
HIPPA Policies & Procedures         DT Williams, MD                                               2

    Other use or disclosure of your medical information will be made only with your
understanding and written authorization to do so.
    New York State has strict rules regarding the diagnosis of AIDS/HIV infection, which will
be respected.

    You generally have the right to request certain restrictions as to the use and release of your
protected health information as delineated below:
    1. You generally have the right to review your medical information and/or to request a copy of
        such information (a fee of $0.75/page will be charged). However, with regard to
        psychotherapy records, some limitations apply. If Dr. Williams’ clinical judgment indicates
        that release of psychotherapy records to you will be harmful to you, another family member,
        or another individual, he may decline to release psychotherapy records to you. He will,
        however, release such records to another licensed psychiatrist or licensed psychotherapist with
        your written authorization. You have the right to a review of this clinical decision.
    2. You have a right to request amendments to your medical record. Such requests must be
        in writing and must state the justification for the request. We will review the request and
        discuss with you the accuracy of the information. You may appeal any disagreement
        concerning your record. We will inform you of your rights and to whom such an appeal
        should be made if such circumstances arise.
    3. You have a right to request an accounting of any disclosure of your medical record
        except for the following:
            a. Disclosures requested by your written authorization
            b. Disclosures to your insurance carrier to obtain payment or clearance for required
                tests and/or treatment. If you have paid Dr. Williams directly for services
                rendered and a subsequent request for information is sent to Dr. Williams by your
                insurance carrier, Dr. Williams will specifically request your written permission
                for release of the records requested, before sending them to any insurance carrier.
            c. Disclosures for national security or public health purposes as permitted by law
            d. As required under 45 CFR Section 154.502
            e. Disclosures to law enforcement officials as permitted by law
            f. Disclosure for research and/or public health purposes after all identifying
                information is removed
            g. Disclosures predating this document

        We are required by law to maintain the privacy of our patients, to protect their medical
records and health information, and to notify them of our privacy practices and their legal rights.
        We are required to abide by the terms of this document as long as it is in effect, and to
notify our patients promptly of any breach of their privacy or any change in our privacy
        We reserve the right to revise this letter if such circumstances become necessary and are
supported by the federal requirements. We will provide our patients with copies of any
documents that supersede this notice.
        Please contact Ms. Shirley J. Samansky, Compliance Officer (3003 New Hyde Park
Road, New Hyde Park, N.Y. 11042; TEL: 516-488-3636) if you feel that your privacy has not
been respected. If you are not satisfied with our explanation and corrective action, you have the
right to file a complaint with the Department of Health and Human Services if you feel your
privacy rights have been violated, without fear of reprisal.
HIPPA Policies & Procedures        DT Williams, MD                                                3
                                                                                  HIPAA 2.17.10


I have been presented with a copy of Dr. Daniel T. Williams’ Notice of Privacy Policies,
detailing the federal and state laws concerning the use and disclosure of my confidential
medical records. I understand the content of this document and request that the following
restrictions concerning the release of my or my child’s medical information be
implemented: (optional)

I agree to permit a copy of this authorization be use in place of the original.

Patient Name: ______________________________ Date of Birth: _____________________

Parent’s Name: ___________________________________ Date: _______________________

Signed: _______________________________________________________________________

Witness: _____________________________________________________________________

Patient or Patient’s representative has refused to sign this document.

Presented on (date and time) ____________________________________________________

By: __________________________________________________________________________

Reason for Refusal: ________________________________________ ____________________


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