Catholic Health and its affiliated covered entities (collectively, Catholic Health) is committed to ensuring that your medical information is private and secure. Catholic Health protects medical information as required by state laws and the federal privacy rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to ensure the security and privacy of your medical records and promote trust between our patients and their health care providers.

Notice of Privacy Practices

Catholic Health maintains a Notice of Privacy Practices that describes the ways in which our covered entities may use and disclose your health information and how you can obtain access to this information. Every patient will be provided with a copy of the Notice when they first come to a Catholic Health provider for treatment and will be asked to sign an acknowledgment that they received a copy of our Notice. Please download the following documents for detailed information on our privacy practices.

Catholic Health Notice of Privacy Practices - English

Catholic Health Notice of Privacy Practices - Spanish

Patient Forms

Inspecting and Obtaining Copies of Your Medical Records

You are entitled to request that a copy of your medical record be released to you or a designated person by downloading and completing the following request form. All forms requesting medical records must be submitted by mail or in person to the Health Information Management (HIM) Department of the specific Catholic Health facility or practice that treated you.

For copies of your billing information, please submit your request in writing to the Director of Patient Accounts at Catholic Health.

Authorization for Release of Health Information Pursuant to HIPAA

Requesting an Amendment to Your Medical Record

You are entitled to request an amendment be made to your medical record by downloading and completing the following request form. This form must be submitted by mail or in person to the Health Information Management (HIM) Department of the specific Catholic Health facility or practice that treated you.

Patient Request for Amendment of Records

*Please note that these forms should NOT be sent to Catholic Health*

The information you are requesting may be available free of charge through Catholic Health MyChart, our secure patient portal. With a Catholic Health MyChart account you can view: test results, immunizations, medication lists, visit and admission summaries, and appointment information from your home computer or compatible smart phone/tablet. Please note: The portal only provides access to portions of the electronic medical record–it is not an all-inclusive medical record. Please ask your doctor about signing up for Catholic Health MyChart.

Contact Information

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Please contact the Catholic Health Compliance Hotline by phone at 866-272-0004 to report a known or suspected violation of a patient’s privacy. You may choose to leave your contact information or report the incident anonymously.

You may also contact the Privacy Officer of the Catholic Health facility or practice directly:

Catholic Health Entity

Privacy Officer

Telephone

Email

Catholic Health Chief Privacy Officer

Lesli Giglio

516-705-3704

Lesli.Giglio@chsli.org

Catholic Health Deputy Privacy Officer

Brian Andrews

516-705-3705

Brian.Andrews@chsli.org

Good Samaritan Hospital

 

Cynthia Vigilante

631-376-3582

Cynthia.Vigilante@chsli.org

St. Catherine of Siena Hospital

 

 

Michelle Goldfarb

 

 

 

631-862-3516

 

 

 

MichelleM.Goldfarb@chsli.org

 

 

St. Charles Hospital

Lisa Oberting

631-474-6759

Lisa.Oberting@chsli.org

Mercy Hospital

Rosemarie Povinelli

516-705-2375

Rosemarie.Povinelli@chsli.org

St. Francis Hospital & Heart Center®

Tiffany Wickes-Demillio

516-562-6551

Tiffany.Wickes-Demillio@chsli.org

St. Joseph Hospital

Blake Benz

516-520-2776

Blake.Benz@chsli.org

Our Lady of Consolation Nursing & Rehabilitation

Dorothy Scholz

631-587-1600 x 6538

Dorothy.Scholz@chsli.org

St. Catherine of Siena Nursing & Rehabilitation & Good Samaritan Nursing & Rehabilitation

Rosemary Swedenburg-Murphy

 

516-705-7196

 

 

Rosemary.Swedenburg-Murphy@chsli.org

 

Catholic Home Care/Good Shepherd Hospice

Igor Nemov

631-828-7404

Igor.Nemov@chsli.org

Maryhaven Center of Hope

Kristin Glassner

631-474-4117 x 2280

Kristin.Glassner@chsli.org

Catholic Health Physician Partners, PC

Monique Ford

631-465-4132

Monique.Ford@chsli.org

Catholic Health Physician Partners, IPA

Linda Iatrou

516-734-0402

Linda.Iatrou@chsli.org

Good Samaritan Hospital
HIM Department
1000 Montauk Highway, West Islip, NY 11795
631-376-4058

Mercy Hospital
HIM Department
1000 North Village Avenue, Rockville Centre, NY 11570
516-570-1173

St. Catherine of Siena Hospital
HIM Department
50 Route 25A, Smithtown, NY 11787
631-862-3080

St. Charles Hospital
HIM Department
200 Belle Terre Road, Port Jefferson, NY 11777
631-474-6123

St. Francis Hospital & Heart Center®
HIM Department
100 Port Washington Boulevard, Roslyn, NY 11576
516-562-6064

St. Joseph Hospital
HIM Department
4295 Hempstead Turnpike, Bethpage, NY 11714
516-520-2822

Catholic Health Home Care
HIM Department
110 Bi-County Boulevard, Farmingdale, NY 11735
631-828-7674

Good Shepherd Hospice
HIM Department
110 Bi-County Boulevard, Farmingdale, NY 11735
631-828-7647

Good Samaritan Nursing & Rehabilitation
HIM Department
101 Elm Street, Sayville, NY 11782
631-669-3160

Our Lady of Consolation Nursing & Rehabilitation
HIM Department
111 Beach Drive, West Islip, NY 11795
631-587-1600 ext. 6538

St. Catherine of Siena Nursing & Rehabilitation
HIM Department
52 Route 25A Smithtown, NY 11787
631-862-3965

Maryhaven Center of Hope
HIM Department
51 Terryville Road, Port Jefferson Station, NY 11776
631-474-4100

Catholic Health Physician Partners

To obtain your medical record or request an amendment from a Catholic Health physician practice, send the forms form directly to the HIM Department of the physician practice.

For Billing Records Only
Catholic Health Services
Patient Accounts
245 Old Country Road, Melville, NY 11747