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Laws & Regulations

Legal Compliance

  • We're committed to operating in accordance with all applicable laws and regulations, to conducting business ethically and honestly, and to acting in a manner that improves our standing in the community.
  • We issue and maintain financial and cost reports, accounting records, research reports, expense accounts, time sheets and other documents that accurately and clearly reflect transactions and financial performance.
  • We don't offer payment, bribes, kickbacks or other incentives to patients, physicians or others to encourage the referral of patients to our facilities or services.
  • We don't accept payments for referrals that we make. Our physicians and other healthcare providers make patient referrals solely based on the patient’s clinical needs. No employee or any other person acting on behalf of Montefiore Nyack Hospital is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients.
  • We don't allow personal interests to influence referrals. Our policy is to inform patients of their options and to promote each patient’s freedom of choice in selecting any services they may require.
  • We don't waive insurance co-payments or otherwise provide financial benefits to patients in return for admission.
  • We handle all patient drugs and controlled substances according to applicable laws and regulations.


  • Antitrust laws are designed to preserve and foster fair and honest competition within the healthcare industry. To accomplish this goal, the language of these laws is deliberately broad, prohibiting such activities as “unfair methods of competition” and agreements “in restraint of trade.” Such language gives enforcement agencies the right to examine many different business activities to judge the effect on competition.
  • Montefiore Nyack Hospital’s policy requires full compliance with all antitrust laws. No employee, under any circumstances, has the authority to approve a violation of the law. Anyone who willingly violates or knowingly permits a subordinate to violate any antitrust law is subject to disciplinary action, including dismissal.
  • The greatest danger for violations of antitrust laws comes from contact with competitors. Therefore, you shouldn't disclose any information concerning the demographic information of patients, services provided by Montefiore Nyack Hospital, future business plans of the Montefiore Nyack Hospital, prices, reimbursements or employees’ salaries.


  • The term “kickback” is defined as the giving of remuneration, which is interpreted under the law as anything of value. Montefiore Nyack Hospital must scrupulously avoid offering or receiving any improper inducement.
  • Any questions concerning these statutes of any questionable business practice that may be subject to the anti-kickback statute should be directed to Montefiore Nyack Hospital’s Compliance Officer.

Not-for-profit tax status

  • Montefiore Nyack Hospital and its affiliates are “not-for-profit” organizations and are therefore exempt from taxation by federal, state and local governments. In order to maintain this exemption, Montefiore Nyack Hospital must operate for the benefit of the community it serves and must avoid “private inurement” and “private benefit.” All nonexempt individuals or entities must pay fair market value for the use of Montefiore Nyack Hospital services and property.
  • Care must also be taken that the Montefiore Nyack Hospital sales tax exemption is used only for legitimate Montefiore Nyack Hospital activities.

Political activity and lobbying

  • It's important to separate personal and Montefiore Nyack Hospital political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials.
  • Certain management personnel may periodically be called on by Montefiore Nyack Hospital to make contact with members of the county, state or federal legislative bodies and other officials to set forth and advocate for Montefiore Nyack Hospital’s positions on issues. These persons are expected to abide by all applicable laws and established policies at all times. Any person who attempts to influence any legislative, executive or other governmental action, official or employee on behalf of Montefiore Nyack Hospital may be required to register as a lobbyist and file reports concerning their activities.

Doing business with the government

  • Very specific rules exist to eliminate the appearance of a conflict of interest by former government employees who upon termination of their government service seek employment with those entities who are regulated by government agencies. If a former government employee or consultant becomes an employee or consultant to Montefiore Nyack Hospital, care should be exercised to insure that the requirements of the U.S. Government Conflict of Interest Laws aren't violated.
  • You may not provide or pay for meals, refreshments, travel or lodging expenses for government employees. Very strict guidelines prohibit any type of gratuity, with very few exceptions, and your strict compliance is required.


  • As a not-for-profit organization, Montefiore Nyack Hospital relies heavily on contributions from donors to support many of its activities. Employees are encouraged to support these fundraising efforts, but are required to coordinate all activities through the Nyack Hospital Foundation.


  • Montefiore Nyack Hospital’s commitment to integrity encompasses all grants received either through government funded programs or through private sources. Montefiore Nyack Hospital has established policies and procedures to ensure that all grants received and their use is consistent with federal, state, local and Montefiore Nyack Hospital rules and regulations.


  • We will not permit retaliation for reporting a perceived or potential violation of the Code of Conduct, Montefiore Nyack Hospital policies/procedures or laws/regulations, or for participation in an investigation of an alleged violation.
  • No disciplinary action or other types of retaliation will be taken against any employee who, in good faith, reports a concern, issue, problem or violation of law, regulation or the Code of Conduct to a manager or supervisor, the Compliance Officer or the Employee Compliance Hotline.
  • Any employee who believes that he or she has suffered retaliation for making a report should contact the Compliance Officer or call the Compliance Hotline at 888-568-8548. Knowingly making a false accusation is a serious violation of organizational policy.

Individual judgment
There are many rules and regulations to follow as an employee of Montefiore Nyack Hospital. If you find yourself feeling unsure of what action to take in any situation, ask yourself the following questions:

  • Is my action consistent with Montefiore Nyack Hospital policy?
  • Could my action give the appearance of impropriety?
  • Will my action discredit any employee or Montefiore Nyack Hospital if disclosed fully to the public?
  • Can I defend my action to my supervisor, other employees and to the public?
  • Does my action meet my personal code of behavior?
  • Does my action conform to the spirit of this Code of Conduct?

Answering these questions honestly may help guide you to the appropriate action. You may also choose to speak to your immediate supervisor for guidance.