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Code of Conduct Policy

Code of Conduct Policy
Initiated: May 2010

Responsible Department(s): Corporate Compliance

1. PURPOSE: To create a standard of conduct and an ethical environment that demonstrates HealthAlliance of the Hudson Valley’s system-wide emphasis on compliance with all policies and procedures, as well as state, federal, and administrative regulations. Moreover, safety and quality thrive in a work environment where teamwork and respect for others are the standard. This Code of Conduct is meant for all employees, physicians, volunteers, and other representatives of HealthAlliance of the Hudson Valley, as well as vendors, suppliers, and independent contractors.


1. Whistleblower: A person who raises a concern about a wrongdoing occurring in an organization or body of people. Usually this person is from the same organization. The revealed misconduct may be classified in many ways: a violation of a law, rule, regulation, policy, or a direct threat to public interest, such as fraud, health/safety violations, and corruption.
2. Anti-Kickback Statute: Prohibits the solicitation, receiving, offering, or paying of any remuneration, directly or indirectly, in cash or in kind, in exchange for a Medicare or Medicaid referral.

3. POLICY: All persons associated with HealthAlliance of the Hudson Valley  have an obligation to behave in ways that merit the trust and confidence of peers, as well as the general public. It is expected that this Code will be discussed and applied to the entire spectrum of responsibilities of all health professionals, including but not limited to, management, clinical and administrative staff, licensed independent practitioners, governing body members, employees, volunteers, and independent contractors. As additional opportunities arise for improving service to HealthAlliance of the Hudson Valley’s patients and its community, pertinent ethical concerns will be incorporated in the Code.


  • Political Activities Policy
  • Acceptance of Gifts Policy
  • Conflict of Interest Policy
  • Whistleblower/Non-Retaliation Policy
  • Internet Policy
  • Scope of Security Services Policy
  • Violence in the Workplace
  • Managing Disruptive Behavior and Physical Violence
  • Notification of a Breach of Unsecured Protected Health Information


5.1 Legal Compliance: HealthAlliance of the Hudson Valley shall strive to ensure all activities are in compliance with all state, federal, local, and administrative regulations, including the following:

  • Anti-trust laws
  • Applicable non-profit tax exemption
  • Restrictions upon political activity
  • Equal employment opportunity
  • Safety and security
  • Anti-kickback statute
  • Document retention and record keeping

5.2 Confidentiality: All employees shall actively protect and safeguard confidential, sensitive, proprietary information, and protected health information in a manner designed to prevent the unauthorized disclosure of such information, in accordance with HIPAA and Hi-Tech laws, as related to the following:

  • Protected health information
  • Organization-specific information
  • Financial information
  • Computer and communication resources

5.3 Business Ethics: HealthAlliance of the Hudson Valley commits to the highest standards of business ethics and integrity and will support and/or enforce the following:

  • Honest communication
  • Appropriate use of proprietary information only
  • Accuracy in financial reporting
  • Compliance with fraud, waste, and abuse laws
  • Conflict of interest policies and procedures
  • Contracts adhering to fair market value standards
  • Gifts and gratuities policy

5.4 Intimidating and/or Disruptive Behavior: The expectation is that all employees, physicians, volunteers, and other representatives of HealthAlliance of the Hudson Valley are held to the highest standards of conduct in all areas related to their employment. Inappropriate conduct of any kind, including but not limited to, disruptive, discourteous, disrespectful, abusive behavior, or any other behavior deemed inappropriate will be subject to disciplinary action based on the circumstances of the situation.

5.5 Response and Discipline: HealthAlliance of the Hudson Valley is committed to creating and fostering a culture in which compliant behavior is encouraged and supported. Those who violate HealthAlliance of the Hudson Valley standards of conduct, compliance policies and procedures, or any law, rule, or regulation under which HealthAlliance operates will be subject to disciplinary action.

  • All employees are obligated to report any violations or suspected violations to their supervisor or the Corporate Compliance Office within 24 hours.
  • Confidential and anonymous reporting may be done on the Hotline, 845.334.4963.
  • Please refer to Non-Retaliation Policy.
  • All complaints received will be investigated immediately.
  • Any disciplinary action will be referred to the Human Resources Department for action.

5.6 Code of Compliance: In keeping with the mission and values of HealthAlliance of the Hudson Valley:

  • Deal openly and honestly with fellow employees, physicians, customers, independent contractors, government entities, and others.
  • Maintain high standard of business and ethical conduct, and adhere to both the spirit and letter of applicable federal, state, and local laws and regulations.
  • Practice good faith in transactions occurring during the course of business.
  • Notify your supervisor or corporate compliance officer of instances of non-compliance.

5.8 Corporate Compliance Contact:

  • Hotline number: 845.334.4963
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