Privacy Forms

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These forms are for printing only.

They can then be filled in and mailed or faxed to the appropriate agencies.

Authorization to Release Information.pdf

Notice of Privacy Practices.pdf

Privacy Practices Complaint Form.pdf

Revocation of Consent Form.pdf

FAX

(845) 704-6173

Postal address

Arms Acres
75 Seminary Hill Road
Carmel, NY 10512

 

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STATEMENT REGARDING PATIENT CONFIDENTIALITY

 

Because Arms Acres operates completely confidential alcohol dependence and substance abuse programs, please be aware that we can neither confirm nor deny the participation of any person in one of our programs without the properly executed written consent of the person inquired about.

 

We adhere strictly to all requirements spelled out in 42 CFR regarding patient confidentiality.  By law, we may only communicate with you if the patient has signed a “Consent to Release Information” which incorporates each of the following items:

 

1.      The name or general designation of the program(s) making the disclosure;

2.      The name of the individual or organization that will receive the disclosure;

3.      The name of the patient who is the subject of the disclosure;

4.      The purpose or need for the disclosure;

5.      How much and what kind of information will be disclosed;

6.      A statement that the patient may revoke the consent at any time, except to the extent that the program has already acted in reliance on it;

7.      The date, event or condition upon which the consent expires if not previously revoked;

8.      The signature of the patient (and/or other authorized person); and

9.      The date on which the consent is signed.

 

Please be aware that it is not our intention to make things more difficult for anyone trying to obtain medically necessary information about any person, but to protect our patients’ right to confidentiality regarding their participation in our programs and any records resulting from such participation.

 

Please download or print our Privacy Forms and have the patient fill it out them completely. (Please be patient, some systems may take awhile to open this file.)

 

If you believe a person to be in treatment at one of our programs currently, we will receive e-mail addressed to that person but can neither confirm nor deny any patient’s participation in any of our programs unless we have a properly executed release on file. While we will make every effort to deliver e-mail addressed to a person we know to be in our facility, we cannot respond on behalf of any individual without written permission to do so.

 

If you require any further assistance to you, please contact our Health Information Management: msaari@libertymgt.com at 845-225-3400.


On April 14, 2003 new federal regulation & legislation have created a mandatory protocol for managing the privacy of the patient population in all types of medical treatment. To be fully informed we suggest you take a look at the HIPPAA [Health Insurance Portability & Accountability Act].

Click the following link for official information or click on the image which is a sample of the page the link will take you to.

http://www.os.dhhs.gov/ocr/hipaa/finalreg.html

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