II.         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 Hospital’s psychiatric unit or drug or alcohol abuse treatment program.

 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 PHI.  However, the Hospital and Health Professionals do not need any type of authorization from you for the following uses and disclosures:

A.            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 Payor will pay for health care.

·         Health Care Operations.  Your PHI mat 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.

B.             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.

C.            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 person’s 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. 

D.            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 surveillance.

E.            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. 

F.            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.

G.            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.

H.            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. 

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

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

K.            Research.  Your PHI may be used or disclosed without your consent or authorization as permitted by Pennsylvania law if an Institutional Review Board approves a waiver of authorization for disclosure. 

L.            Health or Safety.  Your 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.

M.            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.S. Department of State under certain circumstances.

N.            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.

O.            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.

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 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 your PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved. 

B.            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.

C.            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. 

D.            Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Drug or Alcohol Abuse Treatment Program.  Information regarding your care in the Hospital’s psychiatric unit or drug or alcohol abuse treatment program is subject to special protections under state and federal law.  The terms 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 treatment’s or service’s 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, the Hospital 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.

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 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. 

B.            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.

C.            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. 

D.            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.

E.            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 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 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.

F.            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.

G.            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 $1.00 per page of the accounting statement.