ADAP - Notice of Uninsured Care Programs Privacy Practices

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access to this Information. Please Review it Carefully.

Under Federal and New York State law, the Uninsured Care Programs are required to protect the privacy of your Protected Health Information (including medical and billing information and information which is used to make decisions about you), and follow the terms of this notice. Health-related information and personal identifiers provided to the Programs are kept strictly confidential.

The Uninsured Care Programs are also required to give you this notice to tell you how the Uninsured Care Programs may use and give out (disclose) your Protected Health Information held by the Uninsured Care Programs. If the Uninsured Care Programs make any changes to the way your Protected Health Information is used and given out, you will get a new notice by mail. Program staff are aware of your needs for confidentiality and privacy and will disclose personal information only as necessary for the administration of the programs.

The Uninsured Care Programs must use and give out your health-related information:

  • To you or someone who has the legal right to act for you (for example, your health care proxy or a person designated by a specific release signed by you);
  • To the New York State Commissioner of Health and the Federal Office of Civil Rights, if necessary, to make sure your privacy is protected; and
  • When specifically required by law: for example, for health-care oversight activities.

With your permission the Uninsured Care Programs may use and give out your Protected Health Information; for example:

  • To pay for your health care, to provide customer services to you, to resolve any complaints you have and to operate the Uninsured Care Programs;
  • To pay, deny and audit claims for services and to coordinate benefits obtained by you;
  • To pay health insurance premiums and to bill other insurance carriers, including Medicaid, as you specify;
  • To our business associates who assist us in normal business operations; for example, outside auditors, provided they agree to keep your information confidential;
  • To contact you about new or changed benefits under the Uninsured Care Programs; and
  • To contact you about new treatment information or obtain your comments.

The information maintained by the Uninsured Care Programs includes:

  • The Program enrollment application;
  • The medical application form completed by your health care provider;
  • Claim and payment information (up to 7 years only); and
  • Medical information submitted by your health care provider for prior approval medications or services.

By law, you have the right to:

  • See and get a paper copy of this notice, or a copy of your Protected Health Information, held by the Uninsured Care Programs; if you are denied your request for health information, you have the right to seek a review of the denial.
  • Request to have your Protected Health Information amended. If the Uninsured Care Program disagrees with your request (for example, if the information is accurate), you may have a statement of your disagreement added to your Protected Health Information.
  • Get a listing of those receiving your Protected Health Information from the Uninsured Care Programs. The listing will not cover your Protected Health Information that was given out to pay for your health care, health insurance or for the operation of the Uninsured Care Programs.
  • Ask the Uninsured Care Programs to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address).
  • Ask the Uninsured Care Programs to limit how your Protected Health Information is used and given out to pay your claims and operate the Uninsured Care Programs. (Please note that the Uninsured Care Programs may not be able to agree to your request).
  • Be notified in the event of a breach of the privacy or security of your Protected Health Information.
  • You have the right to an electronic copy of Protected Health Information that is maintained electronically. Where the electronic information is not readily producible in the form and format requested, the information will be provided in an alternate readable form and format as agreed to by the Uninsured Care Programs and you.

By law, the Uninsured Care Programs must have your written permission ("authorization") to use or give out your Protected Health Information for any purpose that is not set out in this notice. You may take back (revoke) your written permission at any time, by sending a written notice of revocation.

You can obtain more information about the program or exercise your rights by calling the Privacy Office at the Albany number below or by viewing web information at If you believe the Uninsured Care Programs have violated your privacy rights set out in this notice, you may send your complaint about the Uninsured Care Programs to either of the addresses below:

Privacy Officer
Empire Station
P.O. Box 2052
Albany, NY 12220
Phone: (800) 542-2437
TTY (518) 459-0121


Office of Civil Rights
Department of Health and Human Services
Jacob Javits Federal Building
26 Federal Plaza, Suite 3312
New York, NY 10278
Phone: (212) 264-3313
Fax: (212) 264-3039

Filing a complaint will not affect or subject you to any adverse action or affect your program eligibility under the Uninsured Care Programs.

For more information, call the Uninsured Care Programs at 1-800-542-2437