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.
I. 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.
II. Privacy Obligations
The 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". The Hospital and College are required to provide you with this Notice of legal duties and privacy practices with respect to your Hospital PHI. 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 in Section IV.C, apply to you if you are admitted to Hospital’s psychiatric unit or chemical dependency treatment center.
III. 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 Hospital PHI. However, your authorization is not required for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. Your Hospital PHI, but not your "Highly Confidential Information" (defined in Section IV.C below), may be used or disclosed in order to treat you, obtain payment for services provided to you and conduct the "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 in order to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Hospital and College each may also disclose Hospital PHI to other providers (including each other) involved in your treatment.
· 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. Your Hospital PHI may be disclosed to other providers for them to obtain payment.
· Health Care Operations. Your Hospital PHI may be used and disclosed for health care operations, and may be shared by the Hospital and College for joint health care activities, 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 and shared between the Hospital and College to evaluate the quality and competence of the physicians, nurses and other health care workers, or to train students, residents and fellows. Hospital PHI may be disclosed to a patient relations coordinator in order to resolve any complaints you may have and ensure that you have a comfortable visit in the Hospital.
Your Hospital PHI may also be disclosed to your other health care providers when such Hospital 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.
B. 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 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; or (3) HIV/AIDS . 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. 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 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 College may exercise professional judgment to determine whether a disclosure is in your best interest. 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 may also disclosed in order to notify (or assist in notifying) such persons of your location, general condition or death.
D. Fundraising Communications. Hospital will not use your Hospital PHI for fundraising. College may use basic information about you (such as name, address, dates of service and the like) to contact you to raise funds for College. You are under no obligation to respond to such communications and if you are contacted by College for fundraising purposes, you will be given the opportunity by College to opt out of receiving future fundraising communications.
E. 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 the Pennsylvania Department of Welfare or other 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.
F. Victims of Abuse, Neglect or Domestic Violence. Your Hospital 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.
G. 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.
H. 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.
I. 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.
J. Decedents. Your Hospital PHI may be disclosed to a coroner or medical examiner as authorized by law.
K. Organ and Tissue Procurement. Your Hospital PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
L. Research. Hospital and College engage in important research activities as permitted by Pennsylvania law. Your Hospital PHI may be important to further research efforts and the development of new knowledge. Your Hospital PHI may be used or disclosed without your authorization, if an Institutional Review Board or Privacy Board reviews the research proposal and approves a waiver of authorization for disclosure. Your Hospital PHI may be used or disclosed without your authorization to a researcher who is preparing a research protocol, if the researcher has agreed not to take any of the Hospital PHI away from Hospital during that review
M. Limited Data Set. Limited health information about you (not including your name, address or other direct identifiers) may be provided for research, public health or health care operations, but only if the recipient of such information signs an agreement to protect the information and not use it to identify you.
N. 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 as permitted or required by Pennsylvania law.
O. Specialized Government Functions. Your Hospital PHI may be disclosed to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
P. Workers’ Compensation. Your Hospital 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.
Q. 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.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, 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 Hospital can send your Hospital PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
B. Marketing. Hospital or College will obtain your written authorization ("Your Marketing Authorization") prior to it using your Hospital 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 College 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 College 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, and may share Hospital PHI with each other to enable communication with you about joint health care activities.
C. Uses and Disclosures of Your Highly Confidential Information. As discussed in Section III.A. above, 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:
1. 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.
2. 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.
3. 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.
4. Sexual assault counseling records. Sexual assault victim counseling records will not be disclosed without your authorization.
5. 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.
V. Your Rights Regarding Your Protected Health Information
A. 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 Hospital PHI, you may contact the Hospital Privacy Office at the location identified below. Hospital will notify the College, as appropriate, regarding your concerns. 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. Neither the Hospital nor the College will retaliate against you if you file a complaint with Hospital or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on the uses and disclosures 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 a requested restriction. If you wish to request such additional restrictions, you must use a request form, which may be obtained from Hospital Privacy Office. Hospital will send you a written response.
C. 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. Hospital will notify the College, as appropriate, regarding such matters.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any other written authorization given by you, except to the extent that the Hospital and/or College have taken action in reliance upon it, by delivering a written revocation statement to Hospital Privacy Office identified below. Hospital will communicate revocations, as appropriate, to College. A form of Written Revocation is available upon request from Hospital Privacy Office.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by Hospital in order to inspect and request copies of the records. Under limited circumstances, Hospital may deny you 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 minor’s 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 completed form to the Hospital Privacy Office. If you request copies, you or your next of kin will be charged for the copies in accordance with state and federal law. You will also be charged for the actual postage, shipping or delivery costs, if you request that the copies be mailed to you.
F. Right to Amend Your Records. You have the right to request amendment to the Hospital PHI maintained by Hospital in your Hospital medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from Hospital Privacy Office and submit the completed form to Hospital Privacy Office. Hospital will comply with your request unless the information that would be amended is believed to be accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures. Upon request of Hospital, you may obtain an accounting of certain disclosures of your Hospital PHI made for purposes other than treatment, payment, or health care operations, 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 additional accounting statement.
H. 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 December 8, 2003.
B. 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 maintained by Hospital and/or College, including any information created or received prior to issuing the new notice. If this Notice is changed, Hospital will post the new notice in waiting areas around the Hospital and on the Hospital's Internet sites at www.hahnemannhospital.com. You also may obtain any new notice by contacting the Hospital Privacy Office.
VII. Hospital Privacy Office
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
Broad and Vine Streets
Mail Stop 300
Philadelphia, PA 19102
Telephone Number: (215) 762-3340
or at:
Corporate Privacy Office
Tenet HealthSystem
13737 Noel Road, Suite 100
Dallas, TX 75240
E-mail: PrivacySecurityOffice@tenethealth.com
Ethics Action Line (EAL) 1-800-8-ETHICS