Patient Bill of Rights

Director of Public Health:   
Laurel Headwell, MS   
Assistant Director:   
Angela Stuart Palmer, MS

Supervising PHN:   
Kim Frederick, MS, RN   
Fiscal Manager:   
Tammy Mickan

Office Hours:   
Monday - Friday:   
8:00 AM - 4:00 PM

County Services Complex   
2714 State Highway 29   
Johnstown, NY 12095

(518) 736-5720   
(518) 762-1382

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As a patient, parent, legal guardian of a child receiving home services, or at a clinic operated by the Fulton County Public Health Department, you have the right, consistent with law to understand and use the following rights. If you do not understand or need help, you have the right to assistance, including interpretive services. These rights include New York State Department of Health’s Patients’ Bill of Rights for Diagnostic & Treatment Centers (Clinics) as well as those of Fulton County Public Health in addition to Responsibilities.

(1) Receive service(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, gender identity, national origin or sponsor;

(2) Be treated with consideration, respect and dignity including privacy in treatment;

(3) Be informed of the services available at the center;

(4) Be informed of the provisions for off-hour emergency coverage;

(5) Be informed of and receive an estimate of the charges for services, view a list of the health plans and the hospitals that the center participates with; eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care;

(6) Receive an itemized copy of his/her account statement, upon request;

(7) Obtain from his/her health care practitioner, or the health care practitioner’s delegate, complete and current information concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand;

(8) Receive from his/her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision;

(9) Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his/her action;

(10) Refuse to participate in experimental research;

(11) Voice grievances and recommend changes in policies and services to the center’s staff, the operator and the New York State Department of Health without fear of reprisal;

(12) Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health;

(13) Privacy and confidentiality of all information and records pertaining to the patient’s treatment;

(14) Approve or refuse the release or disclosure of the contents of his/her medical record to any health-care practitioner and/or health-care facility except as required by law or third-party payment contract;

(15) Access to his/her medical record per Section 18 of the Public Health Law, and Subpart 50-3. For additional information link to:;

(16) Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors;

(17) When applicable, make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). The health care proxy is available from the center;

(18) View a list of the health plans and the hospitals that the center participates with; and

(19) Receive an estimate of the amount that you will be billed after services are rendered.

  1. THE RESPONSIBILITY TO: provide information regarding your health status, medical history, and medicine being taken;

  2. THE RESPONSIBILITY TO: notify your private physician and Public Health Staff of any changes in your health condition;

  3. THE RESPONSIBILITY TO: follow the advice and instructions given to you by Public Health Staff;

  4. THE RESPONSIBILITY TO: ask questions of the Public Health Staff to fully understand care given to you;

  5. THE RESPONSIBILITY TO: keep appointments and to notify Public Health of any inability to do so;

  6. THE RESPONSIBILITY TO: cooperate with Public Health Staff of all races, color, sex, religion, age, nationalities, marital status, sexual orientation, and ethnic origin.



Federal Health Information Portability and Accountability Act of 1996

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

We will obtain your written authorization before using your health information or sharing it with others outside the county. However, there are some situations when we do not need your written authorization before using your health information or sharing it with others.

By signing the Patient Information Sheet, you are also acknowledging that you have received this notice

How we may use and disclose your health information without written authorization

For Treatment - FCPH may use medical information to provide patients with medical treatment or services. Departments may disclose medical information to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of patients. For example, a doctor treating an injury may need to know if there are any diseases that would require a special diet so as not to slow the healing process. Different Departments of the County also may share medical information in order to coordinate the different things needed, such as prescriptions, lab work and x-rays. The County may need to disclose medical information to people outside the County Departments who may be involved in medical care after a patient leaves; such as family members, clergy or others used to provide medical services.

For Payment –FCPH may use and disclose medical information so that the treatment and services may be billed to and payment may be collected from the patient, an insurance company or a third party. For example, we may need to give health plan information on treatment, so a health plan will approve treatment for payment or reimbursement.

For Health Care Operations –FCPH may use and disclose medical information for operations. These uses and disclosures are necessary to our Department and make sure that our patients receive quality care. For example, we may use medical information to review treatment and services and to evaluate the performance of staff. FCPH may combine medical information to decide what additional services should be offered, what services are not needed, and whether certain treatments are effective. We may disclose information to doctors, nurses, technicians, and medical students, nursing students and other personnel for review and learning purposes.

Appointment Reminders – FCPH may use and disclose medical information for reminders that there is an appointment for treatment or medical care.

Treatment Alternatives – FCPH may use and disclose medical information to recommend possible treatment options or alternatives.

Health Related Benefits and Services - FCPH may use and disclose medical information to recommend health related benefits or services.

Fundraising Activities – FCPH may use medical information in an effort to raise money for operations.

County Department Directories – Departments within the County do include certain limited information about patients while in their services. This information may include name, location, and religious affiliation, within a specific Department. The directory information, except for religious affiliation, may be released to people who ask for a person by name.

Individuals Involved in Care or Payment for Care - If you do not object, FCPH may release medical information to a friend or family member who is involved with medical care. Medical information may be given to someone who helps pay for care. FCPH may also tell family or friends the condition of a patient.

Exception in Emergencies or Public need -FCPH may disclose medical information in an emergency or for an important public need. We may disclose your information if you need emergency treatment, or if we are required by law to treat you, but are unable to obtain your consent. We also may disclose your information to an entity assisting in a disaster relief effort so that family can be notified about conditions, status and location.

Communication Barriers- FCPH may use or disclose your protected health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.

Research – Under certain circumstances, medical information use and disclosure may be done for research purposes. For example, a Department of Health research project may involve comparing diagnosis of patients. Research projects are subject to a special approval process and permission.

As Required By Law – FCPH will disclose medical information when required to do so by Federal, State or Local law.

To Avert a Serious Threat to Health or Safety – The County may use and disclose medical information when necessary to prevent a serious threat to health, to the public or another person. Any disclosure would be to someone able to help prevent the threat.


Organ and Tissue Donation – FCPH may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation of an organ to donation bank.

Military and Veterans – FCPH may release medical information of members as required by military command authorities or to various veterans departments to determine if you are eligible for certain benefits.

Workers’ Compensation – FCPH may release medical information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks – FCPH may disclose medical information for public health activities. These activities generally include the following:

  • to prevent or control disease, injury or disability;

  • to report births and deaths;

  • to report child/adult abuse or neglect;

  • to report reactions to medications or problems with products;

  • to notify people of recalls of products;

  • 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 believed that someone has been the victim of abuse, neglect or domestic violence.

Health Oversight Activities – FCPH may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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.

Lawsuits and Disputes – FCPH may disclose medical information in response to a court or administrative order. Someone else involved in the dispute may release medical information in response to a subpoena, discovery request, or other lawful process.

Law Enforcement – FCPH may release medical information if asked to do so by law enforcement official:

  • in response to a court order, subpoena, warrant, summons or similar process;

  • to identify or locate a suspect, fugitive, material witness, or missing person;

  • about the victim of a crime if, under certain limited circumstances, the County is unable to obtain the person’s agreement;

  • about a death believed may be the result of a criminal conduct;

  • about criminal conduct at any Department of the County;

  • in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of a person who committed the crime.

Coroners, Medical Examiners and Funeral Directors – FCPH may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. Medical information may be released to funeral directors as necessary to carry out their duties.

National Security Intelligence Activities – FCPH may release medical information to authorized federal officials for intelligence, counterintelligence, and other nation security activities authorized by the law.

Inmates – FCPH may release medical information to correctional institutions or law enforcement officials. This release would be necessary for the institution to provide its inmates with health care, to protect their health and safety and the health and safety of others and for the safety and security of the correctional institution.


Fulton County Public Health will abide by the following rights regarding medical information maintained in its department.

Right to Inspect and Copy – FCPH will allow patients to inspect and copy medical information that may be used to make decisions about care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions, a request in writing needs to be submitted to the department that has control of the information requested. If a copy of the information is requested, the department may charge a fee for the cost of copying, mailing or other supplies associated with the request.

Right to Amend – A patient may request a department to amend medical information if it is felt incorrect or incomplete. To request an amendment, the request must be made in writing and submitted to the department maintaining those records. In addition, the patient must provide a reason that supports the request. The FCPH may deny the request if the department did not create the information, is not part of the medical information kept, or is accurate and complete.

Right to an Accounting of Disclosure – FCPH has the obligation to provide a list of disclosures made of medical information. To request a list or accounting of disclosures, a request, in writing, to the department maintaining those records must be submitted. The request must state a time period, which may not be longer than six years and may not include information dated before April 1, 2003. FCPH may charge for the costs of providing the list.

Right to Request Restrictions – FCPH must allow patients to request a restriction or limitation on the medical information used or disclosed about treatment, payment or health care operations. FCPH will abide by requests to limit medical information to someone who is involved in care or payment, like a family member or friend. For example, not disclosing information about surgery. FCPH will comply with reasonable requests. To request restrictions, a request in writing to the department maintaining those records should be made. The request must tell what information is to be limited, and if the limit is use, disclosure or both and to whom.

Right to Request Confidential Communications – FCPH will abide by reasonable requests to communicate about medical matters in certain ways or at a certain location. For example, a request that communication only be done by mail will be honored. The County will not ask why and will accommodate all reasonable requests.

Rights to a Paper Copy of This Notice of Privacy Practices – FCPH will provide a paper copy of this notice of privacy practices no later than the first encounter after April 14, 2003. This paper notice will be provided either in person or by mail.

CHANGES TO THIS NOTICE Fulton County Public Health and the County of Fulton reserve the right to change this notice. The County reserves the right to make the revised or changed notice effective for medical information we presently have, or any information received in the future. We will post a copy of the current notice in the County Building and on our website. The notice will contain the effective date.


The County will accept any complaint if it is felt that privacy rights have been violated. Complaints may also be filed with the Secretary of the Department of Health and Human Services. To file a complaint with the County, residents and patients will contact Jon Stead, the Chief Privacy Officer for Fulton County. All complaints must be submitted in writing. No penalty will be imposed for filing a complaint.

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by the notice or the laws that apply to Fulton County Public Health will be made only with permission. Permission may be revoked at any time. Any disclosures already made with permission cannot be taken back. Lastly, records of the care provided by the county are required to be retained within each Department that provides the services.

PATIENT CONFIDENTIALITY Procedures for safeguarding health/confidential information maintained by Fulton County:

  1. Records containing individually identifiable protected health information shall be marked and kept in locked files or in rooms that are locked when the records are not in use.

  2. When in use, records shall be maintained in such a manner as to prevent exposure of protected health information to anyone other than the authorized party directly utilizing the case record.

  3. No records shall be taken home by agency staff except upon prior authorization by appropriate supervisory staff in order to perform a function, which requires the possession of the records outside of the department and where return of the records to the department at the close of business would result in an undue burden to staff. In those cases where records are taken home by staff, the records are to be maintained in a secure location and are not to be disclosed to anyone other than those expressly authorized by statute or regulation. The records are to be returned to the department by staff on the following business day.

  4. Records shall be transmitted from one location to another in sealed envelopes stamped “confidential”.

  5. Interviews with patients shall be conducted at a location and in a manner, which maximized privacy. Employees of Fulton County Public Health or the other authorized agencies, consistent with applicable statute and regulation, shall have access to individual Protected Health Information only where the employee’s specific job responsibilities cannot be accomplished without access to Protected Health information.