Joint 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.

WE ARE COMMITTED TO YOUR PRIVACY
Virtua is committed to safeguarding the privacy of your health information. We are required by law to maintain the privacy of your individually identifiable health information (also known as “protected health information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. We will only use and disclose your PHI as described in this Notice. We are required to abide by the terms of this Notice as long as it remains in effect. We reserve the right to change the terms of this Notice at any time and to make the new notice effective for all PHI maintained by us. Any revised notice will be available upon request and posted on our website.

WHO FOLLOWS THIS NOTICE
The terms of this Notice apply to Virtua, and its affiliated entities, programs, and departments, including, but not limited to Virtua Mount Holly Hospital of Burlington County, Virtua Marlton Hospital, Virtua Voorhees Hospital, Virtua Medical Group, Virtua Express Urgent Care, Virtua Health and Rehabilitation Centers, Virtua Home Care Community Nursing Services, Virtua Our Lady of Lourdes Hospital, and Virtua Willingboro Hospital.

The entities above participate in an Organized Health Care Arrangement and may use and share PHI with each other, as necessary to carry out treatment, payment, or health care operations relating to this arrangement.

All Virtua employees, medical staff, trainees, students, volunteers, and agents of Virtua are required to follow the terms of this Notice.

USES AND DISCLOSURES OF YOUR PHI
This section describes the ways we may use or disclose your PHI without first obtaining your consent or authorization.

Treatment: We may use and disclose your PHI as necessary to provide you with medical treatment or services. For example, we may share health information about you with other health care providers- within and outside of Virtua- involved in your care to plan a course of treatment for you, or with a pharmacy that is filling your prescription.

Payment: We may use and disclose your PHI to others for purposes of receiving payment for treatment and services that you receive. For example, we may give information about surgery you had at Virtua to your health plan so it will pay us or reimburse you for the surgery. We also may tell your health plan about a treatment you are going to receive so we can get prior payment approval or learn if your plan will pay for the treatment.

Health Care Operations: We may use and disclose your PHI for operational purposes. This is necessary to operate Virtua, including by ensuring that our patients receive high quality care and that our health care professionals receive superior education. For example, your PHI may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to evaluate the performance of our staff, assess the quality of care and outcomes in your case and similar cases, and learn how to improve our facilities and services.

The sharing of your PHI for treatment, payment, or health care operations may happen electronically, including through My Virtua (patient portal), if you choose to enroll, and Physician Link (provider portal). The exchange of health information electronically enables fast, secure access to your PHI for those participating in and coordinating your care to improve the overall quality of your health and prevent delays in treatment.

Health Information Exchanges: To facilitate the electronic sharing of PHI among those involved in your care, we participate in one or more Health Information Exchanges (HIEs), which coordinate information sharing among HIE participants for purposes of treatment, payment, and health care operations. This means we may share PHI we obtain or create about you with non-Virtua entities involved in your care (such as hospitals, doctors offices, pharmacies, or insurance companies) who participate in the HIE, or we may receive information they create or maintain about you so each of us can provide better treatment and coordination of your health care services. You have the right to opt-out of the HIEs in which we participate. If you opt-out, your PHI will not be made electronically available through the HIE. If you do not opt-out, we may provide your health information to the HIEs in which we participate as permitted by law. If you wish to opt out, you must complete Virtua’s HIE Opt-Out Form and submit the completed form as indicated on the form. The HIE Opt-Out Form is available on our website at www.virtua.org/HIE.

Facility Directories: If you are hospitalized, we may include certain limited information about you in the inpatient directory, including your name, room number, general condition, and, if you wish, your religious affiliation. Unless you object, the information, excluding your religious affiliation, may be disclosed to anyone who requests it by asking for you by name. This information, including your religious affiliation, may also be provided to members of the clergy, even if they do not ask for you by name. If you wish to have your information excluded from this directory, please let a member of your care team know.

Appointments and Services: We may use or disclose your PHI to remind you about appointments, or to let you know about treatment alternatives or other health-related services or benefits that may be of interest to you.

Fundraising. We may use or share your information to contact you to donate to a fundraising effort on behalf of Virtua. You have the right to opt-out of these fundraising communications. Any fundraising communication sent to you will include information on how you can opt-out of receiving similar communications in the future.  

Persons Involved in Your Care. Unless you object, we may disclose your PHI to family, friends, or others identified by you who are involved in caring for you or in paying for your care. We may use or disclose your PHI to notify a family member, personal representative, or any other person responsible for your care of your location and condition. We also may disclose limited PHI to a public or private entity involved in disaster relief efforts to locate a family member or other persons who may be involved in some aspect of your care.

Research. We may use your PHI for research purposes when an institutional review board or privacy board determines there are sufficient protocols in place to ensure the privacy of your PHI.

Business Associates. We may contract with certain outside persons or organizations referred to as “business associates” to perform certain services on our behalf, such as auditing, accreditation, legal services, etc. At times, it may be necessary for us to share your PHI with such outside persons or organizations to enable them to perform services on our behalf. In such instances, we require these business associates and any of their subcontractors to appropriately safeguard the privacy of your PHI.

Additional Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your PHI without your consent or authorization. For example, as permitted by law, we may share your PHI:

• for any purpose required by state and/or federal law;
• for judicial and administrative proceedings pursuant to legal authority;
• with certain governmental agencies if we suspect child abuse or neglect, or if we believe you to be a victim of abuse, neglect, or domestic violence;
• with entities regulated by the Food and Drug Administration, if necessary to report adverse events, product defects, or to participate in product recalls;
• for certain law enforcement purposes, including to identify or locate a suspect, fugitive, material witness, missing person or victim of a crime; to report crimes in emergencies; to report deaths or certain violent injuries; and to meet other mandatory reporting requirements;
• for specialized government functions, such as protection of public officials or reporting to various branches of the armed services if necessary. We also may release your PHI if necessary for national security, intelligence, or protective services activities;
• with a correctional institution or law enforcement official if you are an inmate of a correctional institution or under the custody of a law enforcement official, as necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution;
• to comply with laws and regulations related to workers' compensation;
• for public health activities, such as required reporting of disease, injury, birth, and death, for required public health investigations, and for other health oversight activities;
• with your employer when we have provided health care to you at the request of your employer for purposes related to occupational health and safety. In most cases, you will receive notice that your PHI is being disclosed to your employer;
• with medical examiners, funeral directors, or coroners as necessary for them to carry out their lawful duties;
• if necessary, to arrange for cadaveric, organ, eye, or tissue donation or transplantation; and
• to avert a serious threat to your health or safety or that of any other person as permitted by applicable law.

YOUR AUTHORIZATION

Except as generally outlined above, we will not use or disclose your PHI for other purposes unless you have signed a form authorizing the use or disclosure. The form will describe what information will be disclosed and for how long, to whom, and for what purpose. You have the right to revoke a written authorization to use or disclose your PHI at any time in writing, except your revocation will not apply to the extent Virtua has taken action in reliance on your authorization. We will use or disclose your information only with your written authorization in the following situations:

• when the use or disclosure involves psychotherapy notes;
• when the use or disclosure is for certain marketing purposes, including marketing communications paid for by third parties;
• when the disclosure would constitute a sale of PHI; and
• when the use or disclosure involves a situation not covered in this Notice. 

SPECIAL CONSIDERATIONS

HIV-related information, genetic testing information, substance use disorder treatment records, mental health records, and other types of PHI may have additional confidentiality protections under applicable federal and state laws. We will follow such federal and state requirements that are more stringent than those described in this Notice.  Generally, we may not disclose such information unless you consent in writing, the disclosure is allowed by a court order, or in limited and regulated

other circumstances.

YOUR RIGHTS

This section describes your rights pertaining to your PHI.

Restrictions on Use and Disclosure of Your PHI. You have the right to request a restriction on certain uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree to your restriction request, unless otherwise described in this Notice, but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. If we terminate an agreed-to restriction, we will notify you of such termination. You may request a restriction by submitting the appropriate form, which can be obtained by contacting the Virtua Privacy Office.

Restrictions on Disclosures to Health Plans. You have the right to request a restriction on certain disclosures of your PHI to your health plan. We are required to honor such requests only when you or someone on your behalf, other than your health plan, pays for the health care items(s) or services(s) in full. Such requests must be made in writing and signed by you or your personal representative, as applicable. You may request a restriction by submitting the appropriate form, which can be obtained by contacting the Virtua Privacy Office.

Right to Inspect and Obtain a Copy. With certain exceptions, you have the right to inspect and obtain an electronic or paper copy of the PHI that we maintain in our medical records. To inspect and/or request a copy of your medical records, please contact your physician’s office or the facility where you received services for the appropriate form and instructions on how to submit your written request. We may charge you for a copy of your medical records in accordance with a schedule of fees under federal and state law. You also may access many of your medical records via our patient portal, My Virtua.

Confidential Communications. You have the right to request communications regarding your PHI from Virtua by alternative means or at alternative locations and we will accommodate any reasonable requests by you. Such requests must be made in writing and signed by you or your personal representative, as applicable. The appropriate form can be obtained by contacting the Virtua Privacy Office.

Amendments to Your PHI. You have the right to request an amendment of your PHI that you feel is inaccurate or incomplete. Requests for amendments must be made in writing and signed by you or your personal representative, as applicable, and must state the reason(s) for the request. We may deny your request, but we will tell you why in writing within 60 days. The appropriate form can be obtained from your physician’s office or the facility where you received your care.

Accounting of Disclosures of Your PHI. You have the right to receive an accounting of certain disclosures made by us of your PHI, which do not include disclosures made treatment, payment, and healthcare operations or for certain other limited purposes. This accounting will include disclosures made in the timeframe you request, which may not exceed six years prior to the date on which the accounting is requested. Requests must be made in writing and signed by you or your personal representative, as applicable.  We will provide the first accounting you request in any 12-month period for free. We will charge you a reasonable, cost-based fee for each subsequent accounting you request within a 12-month period. You may request an accounting by submitting the appropriate form, which can be obtained by contacting the Virtua Privacy Office.

Breach Notification. We are required to notify you in writing of any breach of your unsecured PHI without unreasonable delay, but in any event, no later than 60 days after we discover the breach.

Copy of this Notice. You have the right to obtain a paper copy of this Notice. A paper copy of our current Notice will be available at our registration areas. 

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us by contacting the Virtua Privacy Office. You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

CONTACT

If you have questions or would like further information regarding the information in this Notice, please contact the Virtua Privacy Office at 303 Lippincott Drive, 4^th Floor, Marlton, NJ 08053 or by phone at 856-355-6620.  

A copy of this Notice is available in Spanish.

Virtua Health Inc, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: Language assistance services, free of charge, are available to you. Call 1-888-VIRTUA3 or 1-888-847-8823.