NOTICE OF PRIVACY PRACTICES
This notice describes the privacy practices of COMMUNITY LIVING CORPORATION
GROUP (“CLC Group or CLC”) and its affiliates the privacy rights of the people we
serve. It will describe how information about you may be used and disclosed and how
you can get access to this information.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy rule DOES
NOT CHANGE the way you get services from CLC, or the privacy rights you have always
had under federal and state laws. The Privacy rule adds some details about how you
can exercise your rights.
PLEASE REVIEW THIS NOTICE CAREFULLY
This notice is effective as of January 1, 2022.
Our Privacy Commitment to You:
CLC provides services to you. We understand that information about you and your family is
personal. We are committed to protecting your privacy and sharing information only with those
who need to know and are allowed to see the information to assure quality services for you.
CLC is required by law to maintain the privacy of your health information and to provide you
with notice of its legal duties and privacy practices with respect to your health information. This
notice tells you how CLC uses and discloses information about you. It describes your rights
and what CLC’s responsibilities are concerning information about you. When we use the word
“you” in this Notice, we also mean your personal representative. Depending on your
circumstances and in accordance with state law, this may mean your guardian, your health
care proxy, or your involved parent, spouse, or involved adult family member.
If you have questions about any part of this notice or if you want more information about the
privacy practices at CLC, please contact:
Levan Natalishvili, Privacy Officer
Address: Community Living Corp. 135 Radio Circle Drive, Mount Kisco, NY 10549
Who will follow this Notice:
All people who work for CLC will follow this notice. This includes all employees; persons CLC
contracts with who are authorized to provide services to you; assist with providing services to
you; enter information in your record; maintain documentation of services or need to review
your record to provide services to you, and volunteers/student interns who CLC allows to
What information is protected:
All information that we create or keep that relates to your health or care and treatment,
including but not limited to your name, address, birth date, social security number, your
medical information, your service or treatment plan, and other information (including
photographs or other images) about your care in our programs, is considered protected
information. In this Notice, we refer to protected information as protected health information or
“PHI”. We create and collect information about you, and we keep a record of the care and
services you receive though this agency and other service providers. The information about
CLC – Notice of Privacy Practices – January 1, 2022 pg. 2
you is kept in a record; it may be in the form of paper documents in a chart or on a computer.
We refer to the information that we create, collect, and keep as a “record” in this Notice.
Your Health Information Rights:
Unless otherwise required by law, your record is the physical property of CLC, but the
information in it belongs to you and you have the right to have your information kept
confidential. You have the following rights concerning your PHI:
• You have a right to see or inspect your PHI and obtain a copy of the information. Some
exceptions apply, such as information compiled for use in court or administration
proceedings. NOTE: CLC requires you to make your request for records in writing to
the Privacy Officer. You may request copies in paper format or in an electronic form
such as a CD, portable device, or memory stick. In some instances, we may charge
you for copies.
• If we deny your request to see your information, you have the right to request a review
of that denial. The Executive Director/designee will appoint a licensed health care
professional to review the record and decide if you may have access to the record.
• You have the right to ask CLC to change or amend information that you believe is
incorrect or incomplete. We may deny your request in some cases, for example, if the
record was not created by CLC or if after reviewing your request, we believe the record
is accurate and complete.
• You have the right to request a list of the disclosures that CLC has made of your PHI.
The list, however, does not include certain disclosures, such as those made for
treatment, payment, and health care operations, or disclosures made to you or made
to others with your permission.
• You have the right to request a restriction on uses or disclosures of your health
information related to treatment, payment, health care operations and disclosures to
involved family. CLC, however, is not required to agree to your request.
• You have the right to request that CLC communicates with you in a way that will help
keep your information confidential. You may request alternate ways of communication
with you or request that communications are forwarded to alternative locations.
• You have the right to limit disclosures to insurers if you have paid for the service
completely out of pocket.
• You will be notified if there is a breach of unsecured PHI containing your information;
we are required by federal law to provide notification to you.
• To request access to your clinical information or to request any of the rights listed here,
you may contact:
Levan Natalishvili, Privacy Officer
Address: Community Living Corp. 135 Radio Circle Drive, Mount Kisco, NY 10549
We will require you to submit requests in writing to the Privacy Officer.
NOTE: Other regulations may restrict access to HIV/AIDS information, federally
protected education records and federally protected drug and alcohol information. See
any special authorizations or consent forms that will specify what information may be
released and when, or contact the Privacy Officer listed above.
Our Responsibilities to You:
We are required to:
CLC – Notice of Privacy Practices – January 1, 2022 pg. 3
• Maintain the privacy of your information in accordance with federal and state laws.
• Give you this Notice that tells you how we will keep your information private.
• Tell you if we are unable to agree to a limit on the use of disclosure that you request.
• Carry out reasonable requests to communicate information to you by special means
or at other locations.
• Get your written permission to use or disclose your information except for the reasons
explained in this notice.
• We have the right to change our practices regarding the information we keep. If
practices are changed, we will tell you by giving you a new notice.
How CLC Uses and Discloses Your Health Information:
CLC may use and disclose information without your permission for the purposes described
below. For each of the categories of uses and disclosures, we explain what we mean and offer
an example. Not every use or disclosure is described, but all of the ways we will use or disclose
information will fall within these categories.
• Treatment: CLC will use your information to provide you with treatment and services.
We may disclose information to doctors, nurses, psychologists, social workers, and
other CLC personnel, volunteers, or interns who are involved in providing your care.
For example, involved staff may discuss your information to develop and carry out your
treatment or service plan and other CLC staff may share your information to coordinate
different services you need, such as medical tests, respite care, transportation, etc.
We may also need to disclose your information to other providers outside of CLC who
are responsible for providing you with services.
• Payment: CLC will use your information so that we can bill and collect payment from
you, a third party, an insurance company, Medicare or Medicaid, or other government
agencies. For example, we may need to provide your health care insurer with
information about the services you received in our agency or through one of our
programs so they will pay us for the services. In addition, we may disclose your
information to receive prior approval for payment for services you may need. We are
required to disclose information to NYS OPWDD, CLC’s regulatory agency.
• Health Care Operations: CLC will use clinical information for administrative
operations. These uses and disclosures are necessary to operate CLC programs and
to make sure all individuals receive appropriate, quality care. For example, we may
use information for quality improvement to review our treatment and services and to
evaluate the performance of our staff in serving you.
We may also disclose information to clinicians and other personnel for on-the-job training. We
will share your health information with other CLC staff for the purposes of obtaining legal
services from our attorneys, conducting fiscal audits, and for fraud and abuse detection and
compliance through our Compliance Program. We may also disclose information to our
business partners, if any, who need access to the information to perform administrative or
professional services on our behalf.
Other Uses and Disclosures that Do Not Require your Permission:
In addition to treatment, payment, and health care operations, CLC will use your information
without your permission for the following reasons:
• When we are required to do so by federal or state law.
• For public health reasons, including prevention and control of disease, injury or
disability, reporting births and deaths, reporting child abuse or neglect, reporting
CLC – Notice of Privacy Practices – January 1, 2022 pg. 4
reactions to medication or problems with products, and to notify people who may have
been exposed to a disease or are at risk of spreading the disease.
• To report domestic violence and adult abuse or neglect to government authorities
if necessary to prevent serious harm.
• For health oversight activities, including audits, investigations, surveys and
inspections, and licensure. These activities are necessary for government to monitor
the health care system, government programs, and compliance with civil rights laws.
Health oversight activities do not include investigations that are not related to the
receipt of health care or receipt of government benefits in which you are the subject.
• For judicial and administrative proceedings, including hearings and disputes. If you
are involved in a court or administrative proceeding, we will disclose information if the
judge or presiding officer orders us to share the information.
• For law enforcement purposes, in response to a court order or subpoena, to report
a possible crime, to identify a suspect, or witness or missing person, to provide
identifying data in connection with a criminal investigation, and to the district attorney
in furtherance of a criminal investigation of client abuse.
• Upon your death, to coroners or medical examiners for identification purposes or to
determine cause of death, and to funeral directors to allow them to carry out their
• To organ procurement organizations to accomplish cadaver, eye, tissue, or organ
donations in compliance with state law.
• For research purposes when you have agreed to participate in the research and the
Privacy Oversight Committee has approved the use of the clinical information for the
• To prevent or lessen a serious and imminent threat to your health and safety or
• To authorized federal officials for intelligence and other national security activities
authorized by law or to provide protective services to the President and other
• To correctional institutions or law enforcement officials if you are an inmate and
the information is necessary to provide you with health care, protect your health and
safety or that of others, or for the safety of the correctional institution.
• To governmental agencies that administer public benefits if necessary to
coordinate the covered functions of the programs.
Uses and Disclosures that Require Your Agreement:
CLC may disclose information to the following persons if we tell you we are going to use or
disclose it and you agree or do not object:
• To family members and personal representatives who are involved in your care if
the information is relevant to their involvement and to notify them of your condition and
• To disaster relief organizations that need to notify your family about your condition
and location should a disaster occur.
• For fundraising purposes, we may disclose information to a charitable program that
assists us in fundraising with your permission. You have the right to refuse or opt out
if you previously agreed to communications regarding fundraising.
• For marketing of health-related services, we will not use your health information for
marketing communications without your permission.
Authorization Required For All Other Uses and Disclosures:
CLC – Notice of Privacy Practices – January 1, 2022 pg. 5
For all other types of uses and disclosures not described in this Notice, CLC will use or disclose
information only with a written authorization signed by you that states who may receive the
information, what information is to be shared, the purpose of the use or disclosure and an
expiration for the authorization. Written authorizations are always required for the sale of PHI
use and disclosure for marketing purposes, such as agency newsletters and press releases.
Note: If you cannot give permission due to an emergency may release information in your
best interest. We must tell you as soon possible after releasing the information.
You may revoke your authorization at any time. If you revoke your authorization in writing, we
will no longer use or disclose your information for the reasons stated in your authorization. We
cannot, however, take back disclosures we made before you revoked, and we must retain
information that indicates the services we have provided to you.
Changes to this Notice:
We reserve the right to change this Notice. We reserve the right to make changes to terms
described in this Notice and to make the new notice terms effective to all information that CLC
maintains. We will send you the new notice with the effective date.
If you believe your privacy rights have been violated, you may file a complaint with:
• Levan Natalishvili, Privacy Officer
• Address: Community Living Corp. 135 Radio Circle Drive, Mount Kisco, NY 10549
• Phone: 347-524-3618
• Email: firstname.lastname@example.org
Or, you may contact the Director of the Office for Civil Rights, U.S. Department of Health and
Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C.
20201, Secretary of the Department of Health and Human Services. You may call them at
(877) 696-6775, or write to them at 200 Independence Avenue, S.W., Room 509F HHH Bldg.,
Washington, D.C. 20201.
You may file a grievance with the Office of Civil Rights by calling or writing Region II – US
Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza,
Suite 3312, New York, New York 10278, Voice Phone (800) 368-1019, FAX (212) 264-3039,
TDD (800) 537-7697.
All complaints must be submitted in writing. You will not be penalized for filing a complaint.