The Greater Hudson Valley Family Health
Center, Inc.
THE KAPLAN FAMILY PAVILION
147 Lake Street, Newburgh NY 12550
845-563-8000
Welcome to our practice and thank you for choosing The Greater Hudson Valley Family
Health Center to be your health care provider. We understand your time is valuable, so in
order to expedite your visit, below is a list of items you will be required to provide upon your arrival to the health center. New Patient Forms that will also need to be completed can be accessed on the page.
If you are a First time patient at the health center, please call
563-8091 for an appointment. At that time bring with you the following important information:
• Picture Identification i.e., passport, drivers license, green card (for a child – bring the Birth Certificate)
• Insurance Card(s)
• Co-payments
• We accept most major credit cards and checks for payment
• Income Verification will be required for all non-insured patients. If income verification is not provided, please be prepared to pay $120.00 dollars for the visit. Please also note that if your health care provider orders lab work, medical treatments, immunizations,
PPD’s, EKG (these are just a few examples), you will they are an additional cost incurred and you will be required to pay at the time these services are rendered to you.
• Sliding Fee Scale qualifications: If you intend to apply for our Sliding Fee Scale
Program, you will require the assistance of a Patient Services Representative. It is
recommended that you make an appointment at 563-8016 and allow yourself at least one hour prior to your medical appointment time to apply for these services.
In order to apply for sliding fee services and alternate payment arrangements you must bring with you documentation of all household income; your income and that of any individuals who reside in your home. For each we will accept any of the following item(s).
Last 4 Pay stubs, W2 tax statements, Proof of Disability Income, Child Support Statements and/or a letter of support and unemployment benefit letter.
• If your child is uninsured and/or undocumented, they will qualify for health insurance. Please stop and see one of our Patient Service Representatives who can assist you. In our main lobby multiple Managed Care Plans have representatives who you may speak
with about low or no-cost health insurance.
Upon entering the building, please stop at the front desk for direction to the appropriate
department. If you have any questions or concerns, please feel free to call our Site Administrator
at 845-563-8020 or stop by for a visit.
To expedite your visit please complete the following forms prior to your appointment and
bring them with you.
Registration Form– Link
General Consent - Link(Espanol)
Medical History – Link (Espanol)
Notice of Privacy Practices - Link (Espanol)
Important Information
Regarding Patient Information (HIPAA)The Greater Hudson
Valley Family Health Center, Inc. understands that health
information about you and the health care you receive is
personal. We are committed to protecting your personal health
information (PHI). We are committed to maintaining the
confidentially, integrity and security of personal information
entrusted to us by you, our patient. Please take a few
minutes to review the privacy policy of The Greater Hudson
Valley Family Health Center, Inc. You do not have to contact us
to benefit from the center’s privacy practices; the protection
automatically applies to all our patients.NOTICE OF PRIVACY
POLICY:How and Why We Obtain
Personal Information
The Greater Hudson Valley Family Health Center, Inc. uses
personal information collected about you to provide you with the
services you have come to expect from us. We use this
information to provide you the highest level of health care
services, to bill insurance companies and other payers for these
services and to facilitate the day-to-day operations that
support both tasks. The Greater Hudson Valley Family Health
Center, Inc. may collect non-public personal information about
you from any of the following sources:
v
From you or your representative on
application forms (such as, name, address, social security
number, date of birth, phone number).
v
From claims activities (from insurance
companies or other government providers and co-payers).
v
From interactions with other health
care providers (such as, physicians offering specialty services
such as cardiology, oncology, imaging and laboratory services).
v
For verification and consumer
reporting services (such as, insurance and government payers and
credit and collection agencies).
v
From you or your representative
regarding your preferences (such as, to make confirmation calls
to your home or work number, to send clinical information to
your home or another address).
v
From other sources with your consent
or the consent of your representative (such as, from your
employer, legal counsel or another family member).
How We Protect Your
Personal Information
The Greater Hudson Valley Family Health Center, Inc. has always
believed the protection of personal health information (PHI) to
be what is right for our patients and a necessary business
practice. We use information controls in keeping with industry
standards and practices and we regularly adapt and review these
procedure to respond to changing requirements and advances in
technology.
At The Greater Hudson Valley Family Health Center, Inc., access
to your PHI is restricted to our medical staff members and their
support staff for the provision of your health care, others
staff members are restricted access to your PHI unless they
require access to provide you with additional services or to
process claims for payment for care you receive. We may share
such information that we collect with the following:
v
Other Greater Hudson Valley Family
Health Center, Inc. health center sites and medical staff
members.
v
Other specialty physicians or services
(such as, cardiologists, oncologists, imaging and laboratory
services).
v
Insurance companies and governmental
payers for reimbursement purposes (such as, GHI, Blue Cross/Blue
Shield, MVP, Medicaid and Medicare).
v
Governmental Agencies, public health
agencies (such as, reportable infectious diseases, reports of
births and deaths, reports of child abuse or neglect, coroner).
v
Other organizations or entities with
your consent (such as, legal counsel, employer, schools,
insurance companies).
v
Other organizations permitted by the
laws that protect your PHI (such as, fraud and abuse
prevention).
v
For specific research opportunities,
with your consent (such as, when The Greater Hudson Valley
Family Health Center, Inc. participates in regional or national
research study).
Patient Rights
You have the right to inspect and copy the PHI in your
medical and billing records. This right does not include the
right to inspect and copy psychotherapy notes.
To inspect and copy your PHI, you must submit your
request in writing to our Patient Services Administrator. If
you request a copy of the information, we may charge a fee for
the copying and mailing costs, and for any other costs
associated with your request.
You have the right to amend your medical information.
You may request in writing an amendment to your PHI. Requests
should be made to our Patient Services Administrator. Requests
must be in writing. We may deny your request for an amendment.
You have a right to an account of disclosures. You have
the right to receive an accounting of disclosures for purposes
other than treatment, payment or health care operations. Your
request should state a time period and may not include
information before April 14, 2003. The request must be in
writing and addressed to the Patient Services Administrator. We
may charge you for this request.
You have the right to request restrictions. You may ask
us to restrict or limit your PHI as it applies to treatment
payment or health care operations. Such restrictions can
include family members and friends. We are not required to
agree to a restriction that you may request if you physician
believes it is in your best interest to permit use and
disclosure of you PHI. To request a restriction, you must make
your request in writing to the Patient Services Administrator.
In your request, you must tell us what information you want to
limit and to whom you want the limits to apply. You have the
right to request confidential communications. You may
request that we communicate with you in regards to you PHI in a
certain way or at a certain location. For example,
communication as it regards to results of reports and /or
confirmation of visits may be restricted to certain addresses
and/or phone numbers. You should make this request in writing
to the Patient Services Administrator.Complaints
You may file
a complaint with The Greater Hudson Valley Family Health Center,
Inc. and/or with the Secretary of Health and Human Services if
you believe your privacy rights have been violated. You may
file a complaint by mailing or faxing a written description of
your complaint or by telling us about your complaint in person.
Please contact:
The Greater Hudson Valley Family Health Center, Inc.
Attention: Privacy Officer147 Lake Street Newburgh, NY 12550
Please describe what happened and give us the dates and names of
anyone involved. Please also let us know how to contact you so
that we respond to your complaint. You will not be penalized
for filing a complaint.
