Original Effective Date: April 14, 2003
Update Effective Date: September 23, 2013
This notice describes how medical health information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.
This Joint Notice of Privacy Practices (“Joint Notice”) is provided to you pursuant to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPAA”), as amended. It is designed to tell you how we may, under federal law, use or disclose your Protected Health Information.
Who/What is Covered by this Joint Notice?
This Joint Notice covers all Virtua facilities, programs, employees, volunteers, medical residents, and participating members of the physician staff and allied health professionals. The information contained in the record of your medical care generated by Virtua is referred to as Protected Health Information. For maternity patients this Joint Notice covers the use or disclosure of Protected Health Information related to both you and your bab(ies). This Joint Notice applies to all Protected Health Information about you that is maintained by Virtua, including any such information that is maintained in paper or electronic form, or spoken. This includes records of your care maintained by Virtua, whether created by Virtua employees, your physician, consulting physicians, their associated staff and care coordinators, or others covered by this Joint Notice.
This Joint Notice also describes how authorized health care providers may use and disclose your Protected Health Information electronically through the Virtua Health Information Exchange (HIE). You can get additional information about the Virtua HIE from your participating provider’s registrar or receptionist, or by visiting www.virtua.org/HIE.
How We May Use or Disclose Your Protected Health Information
Federal and State Law Implications
HIPAA is a federal law, which places limitations on the types of uses and disclosures health care providers, and others may make of Protected Health Information. At times, State or other regulations may afford more protection of your Protected Health Information or provide additional patient rights that exceed those under HIPAA. Some examples of categories of information that are afforded such additional protections under New Jersey law include HIV/AIDS; Venereal Diseases; Genetic Testing; Drug and Alcohol Treatment facility records; Mental Health facility records; and Minors who independently consent to medical treatment in accordance with State law.
In these and all other applicable cases, Virtua will abide by the most stringent of the regulations as they pertain to Protected Health Information, including obtaining your prior written consent, as required, before any such information is disclosed to a third party. These restrictions also apply to the sharing of any such special categories of information through the Virtua HIE.
Uses and Disclosures Under HIPAA
1. We May Use or Disclose Your Protected Health Information for Purposes of Treatment, Payment or Healthcare Operations without Obtaining Your Prior Authorization Here are a few examples of each category:
- Your Protected Health Information may be provided to physicians, nurses, medical technicians, clerks, their associated staff and care coordinators, and others, for purposes of providing you with medical treatment, care and services. This includes medical staff members and other health care workers not members of the medical staff and who do not work for, or at, Virtua.
- In addition, unless you opt-out, any authorized health care provider who agrees to participate in the Virtua HIE can also electronically access and use your Protected Health Information if needed to provide treatment to you. For instance, if you receive a blood test from one provider in the Virtua HIE network but then are treated by a different provider in the Virtua HIE, both of your treating providers can share your test result electronically through the secure Virtua HIE network, as long as they are otherwise authorized to do so. If you opt-out of the Virtua HIE, your Protected Health Information will continue to be accessed and released, electronically or otherwise, as needed to provide treatment to you, but will not be made available for such purpose through the Virtua HIE.
- The billing department will access Protected Health Information and send relevant information to insurance companies and third party payers so that payment can be made for the services provided..
Health Care Operations
- We may access or send your information to our attorneys, accountants, or other personnel in the event we need the information in order to address one of our own business functions.
- Protected Health Information will be provided to third party “business associates” that perform various activities and services (e.g., billing, transcription, and medical equipment) on behalf of Virtua. In such situations, Virtua will have a written contract in place that restricts the ability of the business associate to use or disclose your Protected Health Information in accordance with HIPAA requirements.
2. Protected Health Information Will Also Be Used Without Prior Authorization Under the Following Circumstances:
- To Notify and/or Communicate with your Family – Unless you inform us of your objection in writing, we will use or disclose your Protected Health Information in order to notify your family or assist in notifying your family, your personal representative or another person responsible for your care about your location, your condition or of your death. We may also discuss your health care with your family involved in your care and, to the extent that they are involved in your care, with your friends. If you are unable or unavailable to agree or object to our discussing these matters with your family and/or friends, our health professionals will use their judgment as to whether any communications with your family or others are necessary and/or appropriate. In certain circumstances we may also disclose your Protected Health Information as authorized for disaster relief purposes.
- For Facility Directories - Unless you inform us of your objection in writing, we will use and disclose in our facility directory your name, location at which you are receiving care, condition (in general terms), and your religious affiliation. All of this information, except for religious affiliation, will be disclosed to people that ask for you by name. Only members of the clergy will be told your religious affiliation.
- As Required by Law – Protected Health Information will be used and disclosed to the extent that such use or disclosure is required by law. Examples of just a few such requirements are: communicable disease reporting, incidence of cancer, burns, seizures, gun shots, abuse, organ donations, product recalls, product failures, birth/deaths and/or birth defects. Examples of just a few of the authorities/agencies to which Protected Health Information may be disclosed include: New Jersey Department of Health and Senior Services, the Division of Motor Vehicles, Local and/or State Police, the Medical Examiner and County Prosecutor, the Perinatal Co-operative, Organ Procurement Agencies, the Drug Enforcement Administration, Immunization records, the Ombudsman, the Office of Civil Rights, the Centers for Medicare and Medicaid Services and/or Peer Review Organizations.
- For Public Health Purposes – Protected Health Information will be provided to local, state or federal public health authorities, as authorized or required by law to prevent or control disease, injury or disability; to report child abuse or neglect; report domestic violence; report to the Food and Drug Administration problems with products and reactions to medications; and report disease or infection exposure.
- For Health Oversight Activities – Protected Health Information will be used and disclosed to health agencies during the course of audits, investigations, surveys, accreditation, certification and other proceedings.
- In Response to Subpoenas or for Judicial and Administrative Proceedings - In general, Protected Health Information may be used and disclosed in the course of an administrative or judicial proceeding. However, we will attempt to ensure that you have been made aware of the use or disclosure of your protect health information prior to its release.
- To Law Enforcement Personnel – Protected Health Information will be used and disclosed to law enforcement officials to identify or locate a suspect, fugitive, material witness or missing person, or, in some cases, to comply with a court order or subpoena and for other law enforcement purposes.
- To Coroners or Funeral Directors - Protected Health Information may be disclosed for purposes of communicating with coroners, medical examiners and funeral directors.
- For Purposes of Organ Donation – Protected Health Information will be used and disclosed for purposes of communicating to organizations involved in procuring, banking or transplanting organs and tissues.
- For Research – Protected Health Information may be used and disclosed to researchers if an Institutional Review Board has approved the waiver of an Authorization and certain other assurances are met.
- For Public Safety – Protected Health Information will be used and disclosed in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
- To Aid Specialized Government Functions - Protected Health Information may be used and disclosed for military or national security purposes. Protected Health Information of patients who are Armed Forces personnel may be used and disclosed: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. Protected Health Information may be used and disclosed to authorized federal officials for conducting national security and intelligence activities.
- For Worker’s Compensation – Protected Health Information may be used and disclosed as necessary to comply with worker’s compensation laws.
- To Correctional Institutions or Law Enforcement Officials – If you are an inmate, Protected Health Information may be disclosed to the correctional institution or law enforcement officials.
- Health Information Exchange (HIE) - Virtua and other healthcare providers participate in a Health Information Exchange which allows patient information to be shared electronically. The HIE allows for immediate electronic access to your participating health care providers and health plans’ pertinent medical information necessary for treatment, payment and operations. If you have not opted-out of the HIE, your information will be available through the HIE to participating health care providers and health plans in accordance with the Notice of Privacy Practices and the law. If you opt-out of the HIE, your personal health information will continue to be used in accordance with this Notice and the law, but will not be made available through the HIE.
3. Required Uses and Disclosures: Under the law, disclosures must be made to you, upon your request (unless medically contraindicated) and when required by the Secretary of the Department of Health and Human Services to investigate or determine compliance with HIPAA.
4. We May Also Use or Disclose Your Protected Health Information for the Following Purposes:
- Appointment/Program Reminders - To contact you with appointment reminders or to provide information on other treatments or health-related benefits and services that may be of interest to you. We will use or disclose your protected health information to communicate with you about our programs and services including disease management, health promotion, preventive care, and wellness programs.
- Fundraising - We may contact you in connection with fundraising activities for Virtua, but you will be afforded the opportunity to elect not to further receive any such communications. You have a right to choose not to receive fundraising communications.
- Change of Ownership - In the event that one or more of the Virtua entities is sold or merged with another organization, your Protected Health Information will become the property of the new owner.
5. For All Other Circumstances, We May Only Use or Disclose Your Protected Health Information After You Have Signed an Authorization. If you authorize us to use or disclose your Protected Health Information for another purpose, you may revoke your authorization in writing at any time. However, the revocation will not be effective to the extent that Virtua has taken action in reliance on the use or disclosure allowed by the Authorization. Unless otherwise permitted by HIPAA, we are required to obtain your authorization in most circumstances for uses and disclosures (a) of psychotherapy notes, (b) for marketing purposes, and (c) circumstances where we would exchange your Protected Health Information for something of value (a “sale”).
Your Rights with Respect to Your Protected Health Information
- 1. You have the right to request restrictions on the uses and disclosures of your Protected Health Information. This means you may ask us not to use or disclose any part of your Protected Health Information for treatment, payment or healthcare operations. You may also request that any part of your Protected Health Information not be disclosed to family members or friends who may be involved in your care, or for notification purposes as described in this Joint Notice. Any such requests for restrictions must be in writing, be addressed to the Privacy Officer and state the specific restriction requested and to whom you want the restriction to apply. However, we are not required to comply with your request, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full.
- With regard to the Virtua HIE only, if you do not wish to allow otherwise authorized doctors, nurses and other individual involved in your care and care coordination to electronically share your Protected Health Information with one another through the Virtua HIE as set forth in this Joint Notice, you can complete, sign and submit the Virtua HIE Opt-Out form to your provider, or by fax or mail as instructed on that form, and we will honor any Opt-Out selection that you make. The Virtua HIE Opt-Out form can be obtained directly from any Virtua HIE-participating provider, or you can download the form from www.virtua.org/HIE or call 1-800-VIRTUA-3. If you opt-out of the Virtua HIE, your Protected Health Information will continue to be accessed and released, electronically or otherwise, as needed to provide treatment to you, but will not be made available for such purpose through the Virtua HIE.
- You have the right to request your Protected Health Information be received by you through confidential means. However, we may condition this accommodation by asking you for information as to how payment will be handled or a specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Your request must be in writing, be addressed to the Privacy Officer and state the specific alternate means or location.
- You have the right to inspect and to obtain a copy of your Protected Health Information, unless such access is determined to be medically contraindicated. If such information is maintained in an Electronic Designated Record Set, your access rights include the right to a copy in an electronic format if readily producible in such format. Virtua will charge you a reasonable cost-based fee for the copying of paper and electronic records, Your right to inspect and obtain a copy of your Protected Health Information extends only to your Protected Health Information contained in Virtua’s Designated Record Set for you. A “Designated Record Set” is the HIPAA term for medical and billing records and any other records that Virtua uses for making health care decisions about you.
- 5. You have a right to request that we amend the Protected Health Information contained in your Designated Record Set if you believe it is incorrect or incomplete. However, we are not required to make any such amendments. If we deny a request, we will provide you with information about our denial and explain how you can disagree with the denial by filing a statement of disagreement with us. We may then prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. All of these documents will be placed in the appropriate part of your Designated Record Set. If you are requesting that we amend your records because you believe that you are a victim of medical identity theft, we will use reasonable efforts to assist you in making corrections to your record which are determined to be appropriate under the circumstances.
- You have a right to receive an accounting of disclosures of your Protected Health Information made by us, except that we do not have to account for disclosures made prior to April 14, 2003 or certain other disclosures, such as those authorized by you; provided in response to an Authorization; made in order to notify and communicate with family; for certain government functions, and/or disclosures provided to you, to name a few. The right to receive an accounting is subject to exceptions, restrictions and limitations.
- You have a right to a paper copy of this Joint Notice of Privacy Practices upon request, even if you have agreed to accept the Joint Notice electronically.
- If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Patient Representative or the Privacy Officer.
Our Duties to You
We are required by law to maintain the privacy of your Protected Health Information and to provide you with a copy of our legal duties and privacy practices with respect to your Protected Health Information in this Joint Notice. We will notify you in the event a Breach occurs affecting your Unsecured Protected Health Information.
We are also required to abide by the terms of this Joint Notice.
We reserve the right to amend this Joint Notice at any time in the future and to make the new Joint Notice provisions applicable to all your Protected Health Information – even if it was created prior to the change in the Joint Notice. If such amendment is made, we will promptly display the revised Joint Notice at our office, and on our Web Site at www.virtua.org
. We will also provide you with a copy, at any time, upon request.
How You May Complain to the Government About our Privacy Practices
You may make complaints to the Office of Civil Rights (OCR) for the New Jersey region if you believe your rights have been violated. You may contact OCR at:
Office for Civil Rights
Jacob Javits Federal Building
26 Federal Plaza - Suite 3312
New York, NY 10278
(212) 264-2355 or Toll Free: 1 (877) 696-6775
We promise not to retaliate against you for any complaint you make to a governmental agency or to our Privacy Officer pertaining to our privacy practices.
How You May Contact us About our Privacy Practices
You may contact us about our privacy practices by calling the Privacy Officer at: (856) 355-6620.