Notice of Privacy Practices 
 
 
 
 

NOTICE OF PRIVACY PRACTICES

 

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 describes the privacy practices of Tenet HealthSystem Hahnemann, L.L.C. which does business as Hahnemann University Hospital ("Hospital"), its workforce, and Philadelphia Health and Education Corporation, which does business as Drexel University College of Medicine, along with its faculty physicians, nurses, and other personnel (collectively, "College"). While Hospital and College engage in many joint activities and provide services in a clinically integrated care setting, they are separate legal entities. This Notice applies to services furnished to you at the Hospital and the Medicine Clinic as a Hospital inpatient or outpatient or any other services provided to you in a Hospital-affiliated program involving the use or disclosure of your health information.

Privacy Obligations

Hospital and College each are required by law to maintain the privacy of your health information maintained by the Hospital, as well as health information used by College that relates to services furnished to you at the Hospital and the Medicine Clinic as a Hospital inpatient or outpatient. Your health information is referred to as ("Hospital Protected Health Information" or "Hospital PHI"). Hospital and College are required to provide you with this Notice of legal duties and privacy practices with respect to your Hospital PHI. Hospital and College use computerized systems that may subject your Hospital PHI to electronic disclosure for purposes of treatment, payment and/or health care operations as described below. When the Hospital and College use or disclose Hospital PHI, the Hospital and College 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 below, apply to you if you are admitted to the Hospital’s psychiatric unit or chemical dependency treatment center.

Permissible Uses and Disclosures Without Your Written Authorization

In certain situations your written authorization must be obtained in order to use and/or disclose your Hospital PHI. However, the Hospital and College 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 Hospital PHI 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 Hospital 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 you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your Hospital PHI may also be disclosed to other providers involved in your treatment. For example, a doctor treating you for a broken leg may need to know if you have diabetes because if you do, this may impact your recovery.
  • Payment. Your Hospital 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 Payor will pay for health care. The physician who reads your x-ray may need to bill you or your Payor for reading of your x-ray therefore your billing information may be shared with the physician who read your x-ray.
  • Health Care Operations. Your Hospital 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, Hospital PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers. Hospital PHI may be disclosed to the Hospital Compliance & Privacy Office in order to resolve any complaints you may have and ensure that you have a comfortable visit. Your Hospital PHI may be provided to various governmental or accreditation entities such as the Joint Commission on Accreditation of Healthcare Organizations to maintain our license and accreditation. In addition, Hospital PHI may be shared with business associates who perform treatment, payment and health care operations services on behalf of the Hospital and College.

Use or Disclosure for Directory of Individuals in Hospital. 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. Information in the directory may be disclosed to anyone who asks for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name. If you do not wish to be included in the facility directory, you will be given an opportunity to object at the time of admission.

Disclosure to Relatives, Close Friends and Other Caregivers. Your Hospital PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you who is involved in your health care or helps pay for your care. 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 College 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/or College would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your Hospital 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 Hospital 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 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.

Victims of Abuse, Neglect or Domestic Violence. Your Hospital PHI may be disclosed to a 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 Hospital 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 Hospital 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 Hospital 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. For example, your Hospital PHI may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.

Correctional Institution. You Hospital PHI may be disclosed to a correctional institution if you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain requests to us.

Business Associates. Your Hospital PHI may be disclosed to business associates or third parties that the Hospital and College have contracted with to perform agreed upon services.

Decedents. Your Hospital PHI may be disclosed to a coroner or medical examiner as authorized by law.

Organ and Tissue Procurement. Your Hospital PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Research. Your Hospital PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.

Health or Safety. Your Hospital PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

Specialized Government Functions. Your Hospital PHI may be disclosed to units of the government with special functions, such as the U.S. military, the U.S. Department of State under certain circumstances such as the Secret Service or NSA to protect, for example, the country or the President.

Workers’ Compensation. Your Hospital PHI may be disclosed as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs.

As Required by Law. Your Hospital PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories; such as required by the FDA, to monitor the safety of a medical device.

Appointment Reminders. Your Hospital PHI may be used to tell or remind you about appointments.

Fundraising. Your Hospital PHI may be used to contact you as a part of fundraising efforts, unless you elect not to receive this type of information.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Use or Disclosure with Your Authorization. For any purpose other than the ones described above, your Hospital PHI may be used or disclosed only when you provide your written authorization on an authorization form ("Your Authorization"). For instance, you will need to execute an authorization form before your Hospital 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 Hospital PHI to send you any marketing materials. (However, marketing materials can be provided you in a face-to-face encounter without obtaining Your Marketing Authorization. Hospital and/or College are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization.) Hospital and/or College may communicate with you in a face-to-face encounter 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.

In addition, the Hospital and/or College may send you treatment communications, unless you elect not to receive this type of communication, for which the Hospital and/or College may receive financial remuneration.

Sale of Hospital PHI. Hospital and College will not disclose your Hospital PHI without your authorization in exchange for direct or indirect payment except in limited circumstances permitted by law. These circumstances include public health activities; research; treatment of the individual; sale, transfer, merger or consolidation of the Hospital; services provided by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their Hospital PHI; and other purposes deemed necessary and appropriate by HHS.

Uses and Disclosures of Your Highly Confidential Information. Certain Pennsylvania laws 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; (5) is about counseling for sexual assault; (6) is to be reported to the State DNA Data Bank. Under Pennsylvania law, the Hospital and College must generally get your authorization to disclose Highly Confidential Information about you, but may disclose it without first getting your authorization in the following circumstances:

  • Mental health treatment. Your mental health treatment records may be disclosed to those who are providing you with treatment. Your mental health treatment records may also be disclosed to someone you identify as being responsible for paying for your care, such as an insurance company, but only the limited amount of information necessary for payment purposes will be disclosed. Your mental health treatment records may be disclosed to the County Mental Health Administrator, a Mental Health Review Officer or to an attorney representing you at a commitment hearing. Your mental health treatment records may be disclosed when required by law, such as to meet a requirement to report suspected child abuse. Regulators such as licensing agencies may review the Hospital and/or College from time to time, and they may have access to your mental health treatment records during those reviews. Other legally authorized reviewers may also review the care and services provided to you, and they may need to have the Hospital and/or College disclose information from your mental health records to them. Your mental health treatment records may be disclosed if the Hospital and/or College are ordered by a court to do so. If you are older than 14 but younger than 18, your mental health treatment records may need to be released to your parent or guardian, if you need medical care that they must agree to. In an emergency, your mental health treatment records may be released in order to prevent someone (including you) from being harmed.
  • Drug and alcohol treatment records. Your drug and alcohol treatment records may be disclosed to a judge who has sentenced you, if your treatment is a condition of the sentence. Your drug and alcohol treatment records may also be disclosed to a judge who has assigned you to a drug and alcohol treatment program under a pre-sentence conditional release program. Your drug and alcohol treatment records may also be disclosed to your probation or parole officer, if your probation or parole is conditioned on you being in treatment. In all other cases, your authorization will be obtained before drug and alcohol treatment records are released. But if you have a medical emergency, your drug and alcohol treatment records may be released to proper medical authorities so that they may provide medical treatment to you.
  • HIV-related information. If you are HIV-positive, information about you that would identify you as being HIV-positive will generally not be disclosed. Certain medications, for example, are typically only given to HIV-positive persons. If you were receiving such a medication, that information would not generally be disclosed without your authorization. HIV-related information may, however, be disclosed without your authorization to a physician who ordered an HIV test, or to health care or social service providers who are providing you with care and services. HIV-related information may be disclosed to your health insurer, so that the Hospital and/or College can get paid for the care and services provided to you. HIV-related information may be disclosed to persons or organizations who review services for peer review, accreditation, licensure, or other oversight activities. HIV-related information may be disclosed about you when required by law—for instance, to the Department of Health. Your HIV-related information may be disclosed to a person so named in a court order. In the event of your death, your HIV-related information may be disclosed to the funeral director who will receive your body. Your HIV-related information may be disclosed to certain county agencies or facilities to help coordinate a youth residential placement for you.
  • Sexual assault counseling records. Sexual assault victim counseling records will not be disclosed without your authorization.
  • Results of DNA Testing. If DNA testing is performed on you for purposes of reporting to the State DNA Data Bank, the results of that testing will only be disclosed to the Data Bank authorities who are authorized to receive it.

 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your Hospital 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 College are not required to agree to these requested restrictions.

You may also request to restrict disclosures of your Hospital PHI to your health plan for payment and healthcare operations purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-pocket in full. Hospital and College must agree to abide by the restriction to your health plan EXCEPT when the disclosure is required by law.

If you wish to request additional restrictions, please obtain a request form from the Health Information Management Office and submit the completed form to the Health Information Management Office. A written response will be sent to you.

Right to Receive Confidential Communications. You may request, and the Hospital and College will accommodate, any reasonable written request for you to receive your Hospital 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 Hospital PHI, except to the extent that the Hospital and/or College have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Health Information Management Office identified below.

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 College in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from the Hospital Health Information Management Office and submit the completed form to the Hospital Health Information Management Office. If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charged the reasonable cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you. However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.

Right to Amend Your Records. You have the right to request that Hospital 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 Health Information Management Office and submit the completed form to the Hospital Health Information Management Office. Your request will be accommodated unless the Hospital and/or College 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 Hospital 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 for 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.

For Further Information or 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 Hospital PHI, you may contact the Hospital Compliance & 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 Compliance & Privacy Office will provide you with the correct address for the Director. Hospital and College will not retaliate against you if you file a complaint with the Hospital Privacy Office or the Director.

Effective Date and Duration of This Notice

 

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

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 Hospital PHI that the Hospital and College 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 and on our Internet site at www.hahnemannhospital.com. You also may obtain any new notice by contacting the Hospital Compliance & Privacy Office.

HOSPITAL CONTACTS:

A single Hospital point of contact is being provided to you for your convenience. The Hospital will forward your communication to the College Privacy Office if your concerns relate to the College or your physician, or as otherwise appropriate.

You may contact the Hospital Privacy Office at:

Hospital Privacy Office

Hahnemann University Hospital

230 N. Broad Street

Mail Stop 300

Philadelphia, PA 19102

Telephone Number: (215) 762-3340

or at:

Corporate Compliance & Privacy Office

Tenet Healthcare

1445 Ross Avenue, Suite 1400

Dallas, Texas 75202

E-mail: PrivacySecurityOffice@tenethealth.com

Phone: 1-877-893-8363 ext. 2009

Ethics Action Line (EAL): 1-800-8-ETHICS

You may contact the Health Information Management Office at:

Health Information Management Office

Hahnemann University Hospital

Broad and Vine Streets

Mail Stop 511

Philadelphia, PA 19102

Telephone Number: (215) 762-7680

 
 
 
 
 

Hahnemann University Hospital | 230 N Broad St, Philadelphia, PA 19102