HIPAA Privacy Practices
Notice of Health Information Practice
Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment
- Means of communication among the many health professionals who contribute to your care
- Legal document describing the care you received
- Means by which you or a third-party payer can verify that services billed were actually provided
- A tool in educating health professionals
- A source of data for medical research
- A source of information for public health officials charged with improving the health of the nation
- A source of data for facility planning and marketing
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:
- Ensure its accuracy
- Better understand who, what, when, where, and why others may access your health information
- Make more informed decisions when authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information as provided by Federal Regulation (45 CFR 164.522). However, the Medical Center is not required to agree to such a request if the facts do not warrant it.
- Obtain a paper copy of the notice of information practices upon request
- Inspect and obtain a copy of your health record as provided for in Federal Regulation (45 CFR 164.524)
- Request an amendment to your health record as provided for in Federal Regulation (45 CFR 164.528)
- Obtain an accounting of disclosures of your health information as provided in Federal Regulation (45 CFR 164.528)
- Request communications of your health information by alternative means or at alternative locations. For example, you may request that we send correspondence to a post office box rather than your home address.
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
Hackensack University Medical Center and our medical and dental staff are a single entity according to Federal Regulation (45 CFR 164.504). With respect to your health record that is created or maintained here we are required to:
- Maintain the privacy of your health information
- Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
- Abide by the terms of this notice
- Notify you if we are unable to agree to a requested restriction
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
- Notify you in case of a breach in the Medical Center’s practice management system and an outsider has obtained your medical information
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, revisions are available at www.HackensackUMC.org or you may request a revised copy from our Consumer Affairs Department.
We will not use or disclose your health information without your authorization, except as described in this notice and for treatment, payment, or health care operations. For example, authorization is required for release of your medical information to an external provider not affiliated with Hackensack University Medical Center, for marketing or fundraising purposes and for receiving information about alternative treatments.
For More Information or to Report a Problem
If have questions and would like additional information, you may contact the Consumer Affairs Department at 201-996-2010. If you believe your privacy rights have been violated, you can file a complaint with the Administrative Director of Consumer Affairs 201-996-2010, or directly with the Secretary of Health and Human Services in Washington (1-877-696-6775). There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health Care Operations
We will use your health information for treatment.
- For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Members of your health care team will record the actions they took, their observations, and their assessments. In that way, your health care team will know how you are responding to treatment.
- We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this facility.
We will use your health care information for payment.
- For example: A bill may be sent to you or a third-party payer (insurance company). The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may provide copies of the applicable portions of your medical record to your insurance company in order to validate your claim.
We will use your health care information for regular health operations.
- For example: Health Care Operations, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
- We may disclose your health information to contractors, agents and other associates who need this information to assist us in carrying our business operations. Our contracts with them require that they protect the privacy of your health information in the same manner as we do.
- Unless you notify us that you object, we will release your name and location in the Medical Center to the general visiting public. In addition, your religious affiliation will be made available to the visiting clergy.
- We may use or disclose information about your location and general condition to notify or assist in notifying a family member, personal representative, or another person responsible for your care.
Communication with Family:
- Health professionals may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to their involvement in your care or payment.
- We may disclose information to researchers when their research has been approved by the Medical Center’s Institutional Review Board (IRB). The IRB reviews the research proposals and establishes protocols to ensure the privacy of your health information.
Funeral Directors or Coroners:
- We may disclose health information to funeral directors or coroners consistent with applicable law to carry out their duties.
Organ Procurement Organizations:
- Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs and eyes for the purpose of tissue donation and transplant.
Telephone Contact/Appointment Reminders:
- We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may call you after you have been a patient to ask about your clinical condition or to assess the quality of care that you received.
- We may contact you as part of a fundraising effort. The information used for this purpose will not disclose any health condition, but may include your name, address, phone number, email address, etc. When contacted, you may ask that we stop any future fundraising requests if you so desire.
- The Medical Center may record digital or film images of you , in whole or in part, for identification, diagnosis or treatment purposes and for internal purposes such as performance improvement or education. Such images may be used for documenting or planning care, teaching, or research. The Medical Center will obtain your authorization for any other use your identifiable image that is unrelated to treatment, payment or heath care operations.
Food and Drug Administration (FDA):
- We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
- We may disclose health information to the extent authorized and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
- As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
- Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
- We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Required by law: We may use or disclose your health information when required to do so by federal, state or local law.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
Hackensack University Medical Center is here to protect our patients and their rights, including respecting the patient’s right to privacy and confidentiality. The Medical Center is committed to providing the highest level of care and services to all patients, while adhering to those rights. Effective Date: April 14, 2003. Revised August 2012.