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Notice of Privacy Practice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Who We Are

Hunterdon Healthcare is affiliated with and has created partnerships with multiple health care providers. This Notice applies to Hunterdon Healthcare and the following individuals and entities participating in an organized health care arrangement with us:

  1. Health care professionals authorized to enter information into your Hunterdon Healthcare Medical Record;
  2. Members of our medical staff, employees, volunteers, trainees, students, and other personnel providing services in Hunterdon Healthcare or any of its affi liated or partnered health care settings;
  3. All departments and units of Hunterdon Healthcare, including our outpatient clinics;
  4. All other patient care settings owned and/or operated by Hunterdon Healthcare, and all medical staff, employees, volunteers, trainees, students or their personnel providing services in these patient care settings.

To obtain an updated list of Hunterdon Healthcare providers covered by this Notice, either visit our website at www.hunterdonhealthcare.org or contact our physician referral service at (800) 511-4462.

Hunterdon Healthcare also participates in electronic health information exchange (HIE) networks, including “Hunterdon Healthy Connections” and “Jersey Health Connect”.  This Notice describes how your authorized providers may access and share your health information electronically through an HIE network.

II. Our Privacy Obligations

We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. When we use or disclose your PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. How We May Use Your PHI Without Your Written Authorization

Hunterdon Healthcare may use and/or disclose your PHI without your written authorization for the following purposes:

A. Treatment, Payment and Health Care Operations.

  1. Treatment. We may use and disclose your PHI to provide treatment and other health care services to you–for example, to diagnose and treat your injury or illness. As part of your treatment, your PHI may be shared among the individuals and entities that are affiliated or have a partnership with Hunterdon Healthcare. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefi ts and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
  2. Payment. We may use and disclose your PHI to obtain payment for services that we provide to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care to verify that they will pay for your health care.
  3. Health Care Operations. We may use and disclose your PHI for our health care operations, and including joint health care operations we may do with other providers who have provided treatment to you or health plans that have paid for your health care.  This may include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use your PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose your PHI for our patient satisfaction survey process. We may disclose your PHI to our Patient Advocate in order to resolve any complaints you may have and ensure that you have a comfortable visit with us. We may also disclose your PHI to another health care facility to which you have been transferred or referred when your PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. We may also contract a third party called a “Business Associate” to perform various health care operations activities and services (e.g., billing, transcription, operating and troubleshooting our health information technology) on our behalf.

B. Directory of Individuals in Hunterdon Healthcare. We may include your name, location in Hunterdon Healthcare, general health condition (e.g., fair, stable, etc.) and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.

 C. Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer from the circumstances that you do not object to the disclosure.  If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

 D. Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of Hunterdon Healthcare. In connection with any fundraising, we may disclose demographic information about you (e.g., your name, address and phone number) and dates we provided health care to you, without your written authorization, to our fundraising staff at Hunterdon Medical Center Foundation. You have the right to opt-out of receiving such fundraising communications, and can do so by contacting the Hunterdon Medical Center Foundation, or our Privacy Offi ce.

 E. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and  neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.  If other public health reporting activities are authorized or required by law, we may disclose your PHI for those purposes as well.

F. Victims of Abuse or Neglect. If we reasonably believe you are a victim of abuse or neglect, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse or neglect.

G. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health care and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid and civil rights laws.

H. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

I. Law Enforcement Officials. We may disclose limited PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.

 J. Decedents. We may disclose your PHI to a funeral director or medical examiner as authorized by law.  Please note that your medical information is no longer protected by HIPAA after 50 years from the date of death.

K. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

L. Research. We may use or disclose your PHI for research purposes with your consent or we will ask our Institutional Review Board to approve a waiver of authorization for disclosure. A waiver of authorization will be based upon assurances from the review board that the researchers will adequately protect your PHI.

M. Preventing a Threat to Health and Safety. We may, consistent with applicable law and standards of ethical conduct, use or disclose your PHI to prevent or lessen a serious or imminent threat to the health or safety of a person or the public.

N. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

O. Workers’ Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

 P. As Required by Law. We may use and disclose your PHI when required to do so by federal or state law.

Q. Health Information Exchange. Hunterdon Healthcare and other health care providers and practices participate with HIE networks that allow patient information to be shared electronically through a secure connected network.  Your health care providers who participate in these HIE networks may have an opportunity to electronically access your pertinent medical information for treatment, payment and certain health care operations. If you do not “Opt-Out” of the HIE network (as described below), your PHI may be made available through such HIE network to your authorized providers in accordance with this Notice and the law.  If you do Opt-Out of the HIE network, your PHI will continue to be used in accordance with this Notice and the law, but will not be electronically available through such HIE network.

lV. When Your Written Authorization Is Required

 A. In General, For All Other Uses & Disclosures. For any purposes other than the ones described above in Section III and exceptions described in this Section IV, we may use or disclose your PHI only when you sign a HIPAA-required authorization form (the “HIPAA Authorization”).  For example, you would be asked to sign a HIPAA Authorization before we send any of your PHI to your life insurance company.

 B. Marketing. We must obtain your signed HIPAA Authorization prior to using your PHI to send you any marketing materials.  We can, however, provide you with marketing materials in a face-to-face encounter, or in the form of a promotional gift of nominal value, without obtaining your signed HIPAA Authorization.

 C. HIV/AIDS Related Information. Before we can disclose any HIV/AIDS-related information about you, you must sign a legally-compliant consent form that specifically asks you if we can disclose your HIV/AIDS-related information. However, state law allows us to disclose your HIV/AIDS information for the following purposes without first obtaining your signed consent: (1) in connection with your diagnosis and treatment; (2) IRB-approved scientific research; (3) management audits, financial audits or program evaluation; (4) medical education; (5) disease prevention and control when permitted by the New Jersey Department of Health and Senior Services; (6) pursuant to a court order under certain circumstances; and (7) when required or otherwise authorized by law, to the Department of Health and Senior Services or another entity.

 D. Genetic Information. Genetic information is considered PHI and is protected by HIPAA just like all your other health information.  In addition, before we can disclose any specific genetic information (for example, your DNA sample) about you, you must sign a legally-compliant consent form that specifi cally asks you if we can disclose your genetic information.  However, federal and state law makes certain exceptions, such as in connection with criminal investigations, paternity tests for a court proceeding, anonymous research, newborn screening, identifying your body, or as otherwise authorized by a court order.

 E. Venereal Disease Information. Before we can disclose any information about you referring to a venereal disease, you must sign a legally-compliant consent form that specifically asks you if we can disclose your venereal disease information. However, state law allows us to disclose your venereal disease information for the following purposes without first obtaining your signed consent: (1) to a prosecuting officer or the court if you are being prosecuted under New Jersey law, (2) to the Department of Health and Senior Services, (3) to your physician, or (4) a health authority, such as the local board of health.

 F. Tuberculosis Information. Before we can disclose any information about you referring to your tuberculosis, you must sign a legally-compliant consent form that specifically asks you if we can disclose your tuberculosis information.  However, there are certain purposes for which we may disclose your tuberculosis information, without obtaining your signed consent, including for (1) research purposes under certain conditions, (2) pursuant to a valid court order, or (3) when the Commissioner of the Department of Health and Senior Services (or his/her designee) determines that such disclosure is necessary to enforce public health laws or to protect the life or health of a named person.

G. Substance Abuse Program Records. Medical records created as part of an alcohol and drug abuse treatment program protected by federal law and regulations called “Part 2” must be kept confidential. Generally, we may not say to a person outside our Part 2 facilities or programs that a patient attends such facility or program, or disclose any information identifying a Part 2 patient as an alcohol or drug abuser unless the patient specifically consents in writing, the disclosure is allowed by court order, or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.

H. Psychotherapy Notes.  We must obtain your signed HIPAA Authorization prior to disclosing any psychotherapy notes.  However, there are certain purposes for which we may disclose psychotherapy notes, without obtaining your HIPAA Authorization, including: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by New Jersey law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.

I. Sale of Your PHI. With certain limited exceptions, we must obtain your signed HIPAA Authorization prior to disclosing your PHI if the disclosure would result either directly or indirectly in financial remuneration to us.

V. Your Rights Regarding Your Protected Health Information

 A. Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If you wish to request restrictions, please obtain a request form from our Privacy Offi ce and submit the completed form to the Privacy Office. We will send you a written response. If we agree to the requested restrictions, we will comply with your request unless PHI is needed for emergency treatment.

 B. Right to Request Confi dential Communications. You may request and we will accommodate any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. If you wish to make a request, please contact our Privacy Office in writing.

 C. Right to Revoke Your HIPAA Authorization. You may revoke your HIPAA Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Offi ce identifi ed below. A form of Written Revocation is available upon request from the Privacy Offi ce.

 D. Right to Request Copy of Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we may charge you a reasonable fee for labor, supplies and postage, up to a maximum allowed under the current law. If you are denied access, you may request that the denial be reviewed. You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record may not be accessible to you (for example, records relating to a minor who sought emancipated care (i.e., without their parent) for pregnancy, abortion, sexually transmitted diseases, substance use or abuse, or contraception and/or family planning services). For PHI that we maintain in any electronic designated record set, you may request and we will provide you with a copy of such PHI in a reasonable electronic format. We may also charge you a reasonable fee for our labor costs and costs associated with providing you with a copy of your PHI in an electronic format, up to the maximum amount allowed under current law.

E. Right to Request an Amendment. You have the right to request that we amend your PHI maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Offi ce. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

 F. Right to Request an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we may charge a reasonable fee for labor, supplies and postage, up to a maximum allowed under the current law.

 G. Right to Notification Following a Breach of Unsecured Protected Health Information. We are required by law to notify you of any unauthorized acquisition, access, use or disclosure of your unsecured PHI without unreasonable delay, but no later than 60 calendar days after we discover the breach.

 H. Opting Out of HIE Networks.  If you do not want to allow otherwise authorized doctors, nurses and other clinicians involved in your care to electronically share your PHI with one another through an HIE network, you have the right to “opt-out”.  Instructions on how to opt-out of a particular HIE network will be provided with the educational brochure that you will receive about such HIE network.   If you opt-out of an HIE network, this will prevent your information from being shared electronically through such network, however it will not impact how your information is otherwise typically accessed and released in accordance with this Notice and the law.

I. Right to Additional Information; and Filing Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office, Patient Advocate or Compliance Office. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278. Also upon request, the Privacy Office can provide you with the additional contact information for the Director. We will not retaliate against you if you file a complaint with the Director or us.

 J. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

 A. Effective Date. This Notice is effective on September 23, 2013.

 B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting areas and on our Internet site at www.hunterdonhealthcare.org. You also may obtain any new notice by contacting the Privacy Office.

VII. Privacy Office

You may contact the Privacy Office at:
Privacy Officer
Hunterdon Healthcare, Compliance Office
2100 Wescott Drive
Flemington, NJ 08822

Telephone Number: (908) 237-5478
E-mail: privacy.office@hunterdonhealthcare.org

 

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