Privacy Policy

North Country Children’s Clinic



This Notice Describes How Medical Information About You And/Or Your Child May Be Used And Disclosed And How You Can Get Access To This Information. Please Read It Carefully.

We understand that medical information about you and/or your child is personal. We are committed to protecting this information. We create a record of the care and services you and/or your child receive at our clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care and/or the care given to your child by this clinic. This notice will tell you about the ways we may use and disclose medical information about you and/or your child. We are required by law to:

  • Make sure that medical information that identifies you and/or your child is kept private.
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you and/or your child.
  • Follow the terms of the notice that is currently in effect.

The following categories describe different ways that we use and disclose medical information. For each category of uses, we will explain what we mean and try to give some examples. Not every use or disclosure will be listed as an example, but, to the best of our ability, we will list all the categories.

1. For Treatment:
We may use medical information about you and/or your child to provide you with medical treatment or services. We may use medical information about you and/or your child with our employees or disclose medical information to other physician’s offices who are involved in taking care of you. For example, our nurse practitioner may need to know if your child has asthma, and she may communicate this to the nurse who may give breathing treatments. If you are referred to a specialist, we may send medical information such as lab results that explains why you are being referred. When a parent/guardian of a minor child designates another person to authorize treatment decisions for that child, NCCC may offer protected health information relative to that decision to the designated person.

2. If your child uses our School Based Clinics:
If your child uses the school-based clinics, we will share certain information with the school nurse’s office. This information will include your child’s height, weight, shot record, the results of vision and hearing screenings and physical exams. Whenever your child is seen at our school based clinics, the school nurse’s office is notified and appropriate information shared so that the school can account for his or her absence from class. If you designate another physician as your primary care provider, we will share information with him or her.

3. For Payment:
We may use and disclose medical information about you so that the treatment and services you receive at the clinic may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about the services you received in the clinic so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.



4. For Health Care Operations:
We may use and disclose medical information about you and/or your child for our clinic operations. To make sure that all our patients receive quality care, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you and/or your child. We may also disclose information to our doctors, nurse practitioners, and health care students and interns, for learning purposes. We may also compare how we cared for you and/or your child with information of how other offices care for their patients to see where we can make improvements in the care we offer. We will make every attempt to remove identifying information from this set of medical information so that others may use it to study health care and health care delivery without learning who specific patients are.

5. Appointment Reminders:
We may use and disclose medical information to contact you as a reminder that you or your child has an appointment with us. We may leave a message asking you to call us.

6. Public Health risks and/or to avert a serious threat to health or safety:
We may use and disclose medical information about your or your child when necessary to prevent a serious threat to you or your child’s safety or the health and safety of the public or another person. This disclosure would only be to someone able to help prevent the threat. For example, we may make reports:

  • To prevent or control certain reportable diseases.
  • To report reactions to medication or problems with products.
  • To notify people of recalls of products they may be using.
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • To notify the appropriate government authority if we believe a child or dependent adult has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required by law.

7. Health Oversight Activities:
We may disclose medical information to a health oversight agency, such as the Department of Health. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

8. As required by Law:
If you and/or your child are involved in a lawsuit or dispute, we may disclose medical information about you and/or your child in response to a court or administrative order. We may also disclose medical information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request, so if you wish, you can obtain an order protecting the information requested. Unless there is legal documentation to the contrary, NCCC may disclose a minor’s PHI to a parent who does not have custody. The signature by one parent on our consent form will be sufficient documentation that we have notified the parents of a minor of our Notice of Privacy Practice.

We will disclose medical information about you and/or your child when required to do so by federal, state or local law. We may release medical information if asked to do so by a law-enforcement official:

  • In response to a court order, subpoena, warrant, or summons.
  • In certain limited circumstances, if we are unable to obtain the person’s permission, we may give information about the victim of a crime.
  • In emergency circumstances, to report a crime; the location of the crime or victims or the identity, description or location of the person who committed the crime.
  • To describe criminal conduct at the clinic.
  • To give information about a death we believe may be the result of criminal conduct.
  • To identify or locate a suspect, fugitive material witness or missing persons.

9. Coroners, Medical Examiners and Funeral Directors:
We may release medical information to identify a deceased person or determine the cause of death. We may release information to funeral directors as necessary to carry out their duties.

10. Organ and Tissue Donation:
If you or your child is an organ donor, we may release medical information to organizations that handle organ procurement or transplantation or to an organ donor bank, as necessary to facilitate organ or tissue donation and transplantation.

11. Military:
If you are a member of the armed forces, or a spouse of a member of the armed forces, we may release medical information about you and/or your child as required by federal law governing requests for information by military command authorities.

12. Worker’s Compensation:
We may release medical information about you for worker’s compensation or similar programs that provide benefits for work related injuries or illnesses.

13. Fund Raising:
We may use certain information (name, address, telephone number, dates of service, age and gender) to contact you in the future to raise money for North Country Children’s Clinic. The money raised will be used to expand and improve the services we provide the community.

You have the following rights regarding medical information we maintain about you and/or your child:

The Right to Inspect and Obtain a Copy of Medical and Billing Records.

If you are a “qualified person”, you may submit a request in writing to the Clinic Coordinator or her designee to inspect and/or obtain a copy of medical records. This request for inspection of your records will be provided within 10 days of the request. A qualified person is the patient, a committee appointed for an incompetent, or a parent of guardian of a patient when that parent or guardian consented to the care and treatment described in the record. If you request a copy of the information, we will ask you to sign a records-release form. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request in certain very limited circumstances as outlined by the Department of Health that include:

  • Personal notes or psychotherapy notes.
  • Information that was disclosed to the practitioner as confidential, including treatment of a minor for reproductive health.
  • Information that the practitioner determines may reasonably be expected to harm the patient or others.
  • Information obtained from other practitioners which may be requested from them directly; for example, consults ordered by another practitioner or old records.

Right to Amend

If you feel that medical information we have about you and your child is incorrect or incomplete, you may ask us to amend the information. This request must be in writing and you must provide a reason that supports your request. We may deny your request to amend information that was not created by us, is not part of the information which you would be permitted to inspect and copy, or is determined by us to be accurate and complete.

Right to an Accounting of Disclosures We Have Made

To request an accounting of disclosures, you must submit your request in writing to the Director of Health. Your request must state a time period, which may not be longer than six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list.

Right to Request Restrictions on Medical Information We Use of Disclose

You have the right to request a restriction on information we use for treatment, payment or health care operations. You have a right to request a restriction on medical information we disclose about you to someone who is involved in your care or the payment for your care. To request restriction, you must make your request in writing, telling us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example disclosures to your spouse. We are not required to agree to your request, but if we do agree, we will comply with your request unless the information is needed to provide you and/or your child emergency treatment.

Right to Request Confidential Communications

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communication, you must make your request in writing to the Clinic Coordinator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

You Have a Right to Have a Paper Copy of This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you and/or your child as well as any information we receive in the future. We will post a copy of the current notice in the clinic. The notice will be dated on all pages.

If you believe your privacy rights have been violated, bring this to the attention of the Clinic Coordinator. If you are not satisfied, you may file a complaint with the clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with the clinic, contact the Director for Health at 238 Arsenal St., Watertown, NY 13601. All complaints should be submitted in writing. You will not be penalized for submitting a complaint.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you and/or your child, you may revoke that permission in writing at any time. If your revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.