Version No. 2 December 8, 2003
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.
Who Presents this Notice
This Notice described the privacy practices of
Roxborough Memorial Hospital (the Hospital), including members
of its workforce, as well as the physician members of the
medical staff, and allied health professionals who practice at
the Hospital. The Hospital and the individual health care
providers together are sometimes called the Hospital and Health
Professionals in this Notice. While the Hospital and Health
Professionals engage in many joint activities and provide
services in a clinically integrated care setting, the Hospital
and Health Professionals each are separate legal entities. This
Notice applies to services furnished to you at Roxborough
Memorial Hospital as a Hospital inpatient or outpatient or any
other services provided to you involving the use or disclosure
of your health information.
Privacy Obligations
The Hospital and Health Professionals 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 legal duties and privacy
practices with respect to your Protected Health Information.
When the Hospital and Health Professionals use or disclose your
Protected Health Information, the Hospital and Health
Professionals are required to abide by the terms of this Notice
(or other notice in effect at the time of the use or
disclosure). Special privacy obligations, described in Section
IV.D, apply to you if you are admitted to the Hospitals
psychiatric unit or drug or alcohol abuse treatment program.
Permissible uses and Disclosures
Without Your Written Authorization
In certain situations, which are described in
Section IV below, your written authorization must be obtained in
order to use and/or disclose your PHI. However, the Hospital and
Health Professionals do not need any type of authorization from
you for the following uses and disclosures:
- Uses and Disclosures For Treatment,
Payment and Health Care Operations.Your PHI, but not your
Highly Confidential Information (defined in Section IV.C
below), may be used and disclosed to treat you, obtain payment
for services provided to you and conduct health care
operations as detailed below:
Treatment.Your PHI may be used and
disclosed to provide treatment and other services to you
for example, to diagnose and treat your injury or illness.
In addition, you may be contacted to provide appointment
reminders or information about treatment alternatives or
other health related benefits and services that may be of
interest to you. Your PHI also may be disclosed to other
providers involved in your treatment.
Payment.Your PHI may be used and
disclosed to obtain payment for services provided 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 (Your
Payor) to verify that Your Payer will pay for health care.
Health Care Operations. Your PHI
may be used and disclosed for health care operations, which
include internal administration and planning and various
activities that improve the quality and cost effectiveness
of the care delivered to you. For example, your PHI may be
used to evaluate the quality and competence of physicians,
nurses and other health care workers. Your PHI may be
disclosed to the Hospital Privacy Office in order to resolve
any complaints you may have and ensure that you have a
comfortable visit.
Your PHI also may be disclosed to your other
health care providers when such 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. In addition, your PHI
may be shared with business associates who perform treatment,
payment and health care operations services on behalf of the
Hospital and Health Professionals.
- Use or Disclosure for Directory of
Individuals in the Hospital.The Hospital may include your
name, location in the Hospital, general health condition and
religious affiliation in a patient directory without obtaining
your authorization unless you object to inclusion in the
directory or are located in a specific ward, wing or unit the
identification of which would reveal that you are receiving
treatment for (1) mental illness, mental health and
developmental disabilities; (2) alcohol and drug abuse; (3)
HIV/AIDS; or (4) child abuse and neglect. Information in the
directory may be disclosed to anyone who asks for you by name or
members of the clergy; provided, however, that your religious
affiliation will only be disclosed to members of the clergy.
- Disclosure to Relatives, Close Friends and
Other Caregivers.Your PHI may be disclosed 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 (1) your agreement is
obtained; (2) you do not object to the disclosure after being
provided an opportunity to object; or (3) it can be reasonably
inferred 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, the Hospital and/or Health Professionals may
exercise professional judgment to determine whether a disclosure
is in your best interests. If information is disclosed to a
family member, other relative or a close personal friend, the
Hospital and Health Professionals would disclose only
information believed to be directly relevant to the persons
involvement with your health care or payment related to your
health care. Your PHI also may be disclosed in order to notify
(or assist in notifying) such persons of your location or
general condition.
- Public Health Activities. Your PHI may
be disclosed 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 the
Pennsylvania Department of Welfare or other 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.
- Victims of Abuse, Neglect or Domestic
Violence.Your PHI may be disclosed to the Pennsylvania
Department of Welfare or other governmental authority, including
a social service or protective services agency, authorized by
law to receive reports of such abuse, neglect, or domestic
violence if there is a reasonable belief that you are a victim
of abuse, neglect or domestic violence.
- Health Oversight Activities.Your PHI
may be disclosed to a health oversight agency that oversees the
health care system and is charged with responsibility for
ensuring compliance with the rules of government health programs
such as Medicare or Medicaid.
- Judicial and Administrative Proceedings.Your PHI may be disclosed in the course of a judicial or
administrative proceeding in response to a legal order or other
lawful process.
- Law Enforcement Officials.Your PHI
may be disclosed 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.
- Decedents. Your PHI may be disclosed
to a coroner or medical examiner as authorized by law.
- Organ and Tissue Procurement.Your PHI
may be disclosed to organizations that facilitate organ, eye or
tissue procurement, banking or transplantation.
- Research.Your PHI may be used or
disclosed without your consent or authorization as permitted by
Pennsylvania law if an Institutional Review Board/Privacy Board
approves a waiver of authorization for disclosure.
- Health or Safety.Your PHI may be used
or disclosed to prevent or lessen a serious and imminent threat
to a persons or the publics health or safety as permitted or
required by Pennsylvania law.
- Specialized Government Functions. Your
PHI may be used and disclosed to units of the government with
special functions, such as the U.S. Military or the U.D.
Department of State under certain circumstances.
- Workers Compensation.Your PHI may be
disclosed as authorized by and to the extent necessary to comply
with Pennsylvania law relating to workers compensation or other
similar programs.
- As Required by Law.Your PHI may be
used and disclosed when required to do so by any other law not
already referred to in the preceding categories.
Uses and Disclosures Requiring Your Written Authorization
- Use or Disclosure with Your Authorization.For any purpose other than the ones described above in Section
III, your PHI may be used or disclosed only when you grant your
written authorization on an authorization form (Your
Authorization). For instance, you will need to execute an
authorization form before you PHI can be sent to your life
insurance company or to the attorney representing the other
party in litigation in which you are involved.
- Marketing.Your written authorization
(Your Marketing Authorization) also must be obtained prior to
using your PHI to send you any marketing materials. (However,
marketing materials can be provided to you in a face-to-face
encounter without obtaining Your Marketing Authorization. The
Hospital and Health Professionals are also permitted to give you
a promotional gift of nominal value, if they so choose, without
obtaining Your Marketing Authorization.) In addition, the
Hospital and Health Professionals may communicate with you about
products or services relating to your treatment, case management
or care coordination, or alternative treatments, therapies,
providers or care settings without Your Marketing Authorization.
- Uses and Disclosures of Your Highly
Confidential Information.In addition, federal and state law
require special privacy protections for certain highly
confidential information about you (Highly Confidential
Information), including the subset of your PHI that: (1) is
maintained in psychotherapy notes; (2) is about mental illness,
mental health and developmental disabilities services; (3) is
about alcohol and drug abuse prevention, treatment, and
referral; (4) is about HIV/AIDS testing, diagnosis or treatment;
or (5) is about child abuse and neglect. In order for your
Highly Confidential Information to be disclosed for a purpose
other than those permitted by law, your written authorization
must be obtained.
- Use and Disclosure of Information Upon
Admission to a Psychiatric Unit or Drug or Alcohol abuse
Treatment Program. Information regarding your care in the
Hospitals psychiatric unit or drug or alcohol abuse treatment
program is subject to special protections under state and
federal law. The term of this Notice shall apply to your PHI
unless otherwise described in this Section IV.D. For any
disclosures of PHI to any individual(s) set forth below, the
Hospital and Health Professionals will only disclose the
relevant and necessary information.
Psychiatric Treatment.The Hospital
and/or Health Professionals will disclose relevant portions
or summaries of your PHI to individuals actively engaged in
your treatment. The Hospital and/or Health Professionals
will disclose relevant portions or summaries of your PHI
(limited to staff names, dates, types and costs of therapies
and services, and a short description of each treatments or
services purpose) to third party payors. On occasion, the
Hospital and/or Health Professionals may use or disclose
relevant portions or summaries of your PHI for certain
health care operations (for example, to reviewers and
inspectors to obtain certification as an eligible provider,
to individuals for utilization reviews) but, to the extent
possible, your personally identifiable information will be
removed. The Hospital and Health Professionals will not
respond to inquiries about your treatment and will not
disclose information revealing that you are a patient of the
psychiatric unit to unauthorized individuals who call the
Hospital to seek information. Your PHI will not be disclosed
to a family member, relative or any other person seeking
information about your care without your written
Authorization. If you are a minor or have a personal
representative (such as a guardian or person authorized
under a power of attorney), you will be consulted prior to
sharing information with such person. If you refuse to grant
permission or are unable to grant permission, your information may be shared with your personal representative
only to the extent permitted or required by state law. The Hospital and Health Professionals will comply with state law
in reporting relevant portions or summaries of your PHI for
public health activities or health oversight activities,
such as reporting PHI to the administrator of the pertinent
county mental health and mental retardation program. If you
disclose information related to child abuse or other types
of actual or threatened abuse, in accordance with
Pennsylvania law the Hospital and Health Professionals may
be required to report such information to governmental
authorities responsible to investigate such abuse, such as
the Department of Public Welfare. If you commit a crime on
the premises, the Hospital and Health Professionals may use
relevant portions or summaries of your PHI to report the
crime. If there is an emergency situation, then necessary
portions of your PHI may be disclosed in response to such
emergency situation. To the extent possible you will be
notified or a protective order will be sought prior to
disclosing information pursuant to a judicial or
administrative proceeding. Your PHI will not be used for
marketing. In accordance with Pennsylvania law, when the
Hospital and/or Health Professionals release your mental
health records, with or without your Authorization, the
Hospital and Health Professionals will accompany such
release with the following statement: This information has
been disclosed to you from records whose confidentiality is
protected by State statute. State regulations limit your
right to make any further disclosure of this information
without prior written consent of the person to whom it
pertains. The Hospital and Health Professionals are
required by Pennsylvania law to give you the right to enter
into your record a written statement correcting information
in that record that you believe is false or misleading.
Drug or Alcohol Abuse Treatment.If
you are a recipient of drug or alcohol abuse treatment, your
PHI is protected by federal confidentiality laws (42 U.S.C.
290dd-3, 290ee-3 and 42 CFR Part 2) and Pennsylvania law.
Violations of these laws is a crime and may be reported to
appropriate authorities. Your PHI will be disclosed to
Hospital personnel within the drug or alcohol abuse
treatment program and certain organizations providing
services to the program that have a need to know your PHI to
perform their job duties or to medical personnel in the
event that your life is in immediate jeopardy. Your
authorization will be obtained prior to disclosing any PHI
to obtain payment for services rendered to you, such as for
example, to your insurance company. On occasion, your PHI
may be used for health care operations but will remove your
identifying information. The Hospital and Health
Professionals will not respond to inquiries about your
treatment and will not disclose information revealing that
you are a patient of the drug or alcohol abuse treatment
program to unauthorized individuals who call the Hospital to
seek information. Your PHI will not be disclosed to a family
member, relative or any other person seeking information
about your care without your written Authorization. If you
are a minor or have a personal representative (such as a
guardian or person authorized under a power of attorney),
you will be consulted prior to sharing information with such
person. If you refuse to grant permission or are unable to
grant permission, information may be shared with your personal representative only to the extent permitted or
required by state law. The Hospital and Health Professionals
will comply with federal and state law in reporting your PHI
for public health activities or health oversight activities.
If you disclose information related to child abuse, theHospital and Health Professionals may be required to report
such information to governmental authorities responsible to
investigate such abuse. If you commit a crime on the
premises your PHI may be used to report the crime. If a
judicial or administrative court issues an order after
application of good cause, then the Hospital and/or Health
Professionals will disclose relevant information pursuant to
the order. Your PHI will not be used for marketing.
Your Rights Regarding Your Protected
Health Information
- For Further Information: Complaints.If you desire further information about your privacy rights, are
concerned that your privacy rights have been violated or
disagree with a decision made about access to your PHI, you may
contact the Hospital Privacy Office. You may also file written
complaints with the Director, Office for Civil Rights of the
U.S. Department of health and Human Services. Upon request, the
Hospital Privacy Office will provide you with the correct
address for the Director. The Hospital and Health Professionals
will not retaliate against you if you file a complaint with the
Hospital Privacy Office or the Director.
- Right to Request Additional Restrictions.You may request restrictions on the 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 all
requests for additional restrictions will be carefully
considered, the Hospital and Health Professionals are not
required to agree to a requested restriction. If you wish to
request additional restrictions, please obtain a request form
from the Hospital Privacy Office and submit the completed form
to the Hospital Privacy Office. A written response will be sent
to you.
- Right to Receive Confidential
Communications.You may request, and the Hospital and Health
Professionals will accommodate, any reasonable written request
for you to receive your PHI by alternative means of
communication or at alternative locations.
- Right to Revoke Your Authorization.You may revoke Your Authorization, Your Marketing Authorization
or any written authorization obtained in connection with your
Highly Confidential Information, except to the extent that the
Hospital and/or Health Professionals have taken action in
reliance upon it, by delivering a written revocation statement
to the Hospital Privacy Office identified below. A form of
written revocation is available upon request from the Hospital
Privacy Office.
- Right to Inspect and Copy Your Health
Information.You may request access to your medical record
file and billing records maintained by the Hospital and Health
Professionals in order to inspect and request copies of the
records. Under limited circumstances, you may be denied access
to a portion of your records. You should take note that, if you
are a parent or legal guardian of a minor, certain portions of
the minors medical record will not be accessible to you (for
example, records relating to abortion, treatment or testing for
venereal diseases or other reportable diseases, alcohol and drug
abuse prevention, treatment, and referral). If you desire access
to your records, please obtain a record request form from the
Hospital Privacy Office and submit the complete form to the
Hospital Privacy Office. If you request copies, you or your next
of kin will be charged in accordance with federal and state law.
You also will be charged for the actual postage, shipping or
delivery costs, if you request that the copies be mailed to you.
- Right to Amend Your Records. You have the
right to request that PHI maintained in your medical record file
or billing records be amended. If you desire to amend your
records, please obtain an amendment request form from the
Hospital Privacy Office and submit the completed form to the
Hospital Privacy Office. Your request will be accommodated
unless the Hospital and/or Health Professionals believe that the
information that would be amended is accurate and complete or
other special circumstances apply.
- Right to Receive An Accounting of
Disclosures.Upon request, you may obtain an accounting of
certain disclosures of your PHI made 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, you will be charged
$0.50 per page of the accounting statement.
- 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.
Effective Date and Duration of This
Notice
- Effective Date.This Notice is
effective on December 8, 2003.
- Right to Change Terms of this Notice.The terms of this Notice may be changed at any time. If this
Notice is changed, the new notice terms may be made effective
for all PHI that the Hospital and Health Professionals maintain,
including any information created or received prior to issuing
the new notice. If this Notice is changed, the new notice will
be posted in waiting areas around the Hospital.
Hospital Privacy Office
You may contact the Hospital Privacy Office at:
Hospital Privacy Office,
Roxborough Memorial
Hospital,
5800 Ridge Ave.,
Philadelphia, Pennsylvania 19128.
Telephone Number : (215) 487-4245 |
