Privacy Practices

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Effective Date: April 14, 2003
Revised: September 23, 2013

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

This Notice is provided to you pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its implementation regulations, as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH) and the Final HIPAA Rule. It is designed to tell you how we may, under federal law, use or disclose your health information and inform you of your rights.  If you have any questions about this Notice, please contact our Privacy Office at 609-926-4300 or 1-866-314-4722

I. OUR COMMITMENT TO YOUR PRIVACY 

We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice. HIPAA places certain obligation upon us with regard to your PHI. Accordingly, when we need to use or disclose your PHI, we will fully comply with the terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

II. WHO WILL FOLLOW THIS NOTICE
This Notice describes Shore Medical Center’s practices and that of:

• Any health care professional authorized to document in your medical record.  For example, physicians, nursing staff, or therapists. 
• All departments and units of the medical center such as the laboratory, radiology, or patient billing.
• Any member of a volunteer group we allow to help you while you are at or receiving services from Shore Medical Center.
• All members of our workforce including employees, staff and other medical center personnel.
• All members of the SMC Organized Health Care Arrangement (OHCA).
• All Shore Medical Center (previously Shore Memorial Hospital) entities and off-site locations. These entities and off-site locations may share your protected PHI with each other for treatment, payment or medical center operations described in this Notice.

III. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION THAT DO NOT REQUIRE YOUR AUTHORIZATION  

In certain situations, described in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI.  However, we do not need your authorization for the following uses and disclosures:

TREATMENT
We may use your PHI to provide you with treatment or related services.  We may disclose your information to physicians, nurses, technicians, or other medical center personnel or trainees providing you treatment or services. For example, doctors and staff of various departments may share your information in order to coordinate the treatment and services you need, such as prescriptions, lab work, x-rays, as well as your meals or discharge arrangements.

PAYMENT
We may use your information, and send relevant parts to your insurance companies, in order to determine your eligibility and benefits for services you receive and obtain payment for the services we provided to you.

HEALTH CARE OPERATIONS
We may use and disclose your PHI to run our organization and assure quality care for our patients.  For example, we may use this information to review our treatment and services; to evaluate the performance of our staff; to decide what additional services or treatments we should offer or if new treatments are effective.
We may ask that you sign-in when you come in; we may call your name in the waiting room; we may post your name on a census board for location purposes.
We may also provide your information to our attorneys, accountants or other business associates, performing various activities on our behalf or to address one of our own business functions. In such situations, we will have a written contract in place (the “Business Associate Agreement”) limiting their rights to use or disclose the information in accordance with HIPAA requirements. 

APPOINTMENT REMINDERS
We may use and disclose your protected PHI to contact you as a reminder that you have an appointment for treatment, testing, or medical care.

TREATMENT ALTERNATIVES
We may use and disclose your protected PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

HEALTH-RELATED BENEFITS AND SERVICES
We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.

MEDICAL CENTER DIRECTORY
We may include certain limited information about you in our directory while you are a patient at Shore Medical Center.  This information may include your name, location, your general condition (for example fair, good, etc.) and your religious affiliation.  Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name.  This directory information, except for your religious affiliation, may also be released to people who ask for you by name.  The purpose of this is so your family, friends, and clergy can visit you while you are in Shore Medical Center.

If you do not want to be listed in the hospital directory, you must inform a member of our registration staff.  You will be asked to put this request in writing.

FUNDRAISING ACTIVITIES
We may use your PHI to contact you in an effort to raise money for the medical center and its operations.  We may disclose your information to our foundation so it may contact you in raising money for the center. We would release only your name, address and phone number and/or certain other limited information.
You have the right to opt-out of receiving these communications and may do so at any time by notifying the Shore Medical Center Foundation in writing. 

HEALTH INFORMATION EXCHANGE (HIE)
Shore Medical Center and other health providers participate in an electronic Health Information Exchange (HIE). We and the other participants may use, disclose and access your information through the HIE for the purpose of treatment, payment and operations to the extent permitted by law. You have the right to “opt-out” or decline to participate in the HIE and we will provide you with this right at the earliest opportunity. If you choose to opt-out, your information will continue to be used in accordance with the Notice and the law. However, your information created after the opt-out will not be maintained in HIE. You also have the right to rescind your opt-out.

OTHER HEALTHCARE PROVIDERS
We may disclose your PHI  to other health care professionals as required by them to treat you, or obtain payment for the services they provided you with or other own health care operations.

DISCLOSURE TO RELATIVES, CLOSE FRIENDS, CAREGIVERS
We may release your PHI to family members and relatives, close friends, caregivers or other individuals that you may identify as long as we:

• Obtain your agreement:
• Provide you with the opportunity to object to the disclosure and you do not object: or,
• We reasonably infer that you would not object to the disclosure.

If you are not present, or unable to agree or object to a use or disclosure we may exercise our professional judgment to determine whether such use or disclosure would be in your best interests.We may also disclose your PHI in order to notify or assist with notifying such persons of your location, general condition or death. You may at any time request that we do not disclose your PHI to any of these individuals.

RESEARCH
Generally, we will ask for your written authorization to use or disclose your PHI for research purposes. However, we may use or disclose your information for research purposes without authorization if our Institutional Review Board has waived the authorization requirement.

PUBLIC HEALTH ACTIVITIES
We may disclose your PHI to public health authorities that are authorized by law to receive and collect this information in order to:

• prevent or control disease, injury, or disability;
• report births and deaths;
• report suspected or actual abuse, neglect, or domestic violence involving a child or an adult;
• report adverse reactions to medications or problems with health care products;
• notify individuals of product recalls they may be using;
• notify an individual who may have been exposed to a disease or may be at risk for spreading or contracting a disease or condition;
• report certain immunization information where required by law, such as the state immunization registry or to your child’s school;
• report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

HEALTH OVERSIGHT ACTIVITIES
We may disclose your PHI to a health oversight agency such as Medicare or Medicaid that oversees health care systems and delivery to assist with audits or investigations designed to ensure compliance with such government health care programs. We may also disclose your information to other agencies whose oversight activities may include, for example, audits, inspections, and licensure or certification surveys. 

JUDICIAL OR ADMINISTRATIVE PROCEEDINGS
We may disclose your PHI pursuant to a court order, subpoena or other lawful process in the course of a judicial or administrative proceeding.  For example, we may disclose your PHI in the course of a lawsuit you have initiated against another person(s) for compensation or damage for personal injuries you received to that person(s) or his insurance carrier.

LAW ENFORCEMENT
We may disclose your PHI in a response to a request by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process
• to identify or locate a suspect, fugitive, material witness, or missing person
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
• about a death we believe may be the result of a criminal conduct
• about criminal conduct at the hospital
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
We may use or disclose your PHI, as necessary, to prevent a serious threat to the health or safety of you or other individuals.  Any such use or disclosure would be made solely to the individual(s) or organization(s) that have the ability and/or the authority to assist in preventing the threat.

WORKERS COMPENSATION
We may disclose your PHI to worker’s compensation programs when your health condition arises out of a work-related illness or injury.

ORGAN AND TISSUE DONATION
We may use or disclose your PHI to authorized organ/tissue procurement organizations, as necessary, to facilitate organ, eye or tissue procurement, banking, or transplantation.

CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS
We may disclose your PHI to a coroner or medical examiner in order to, for example, identify a deceased person or determine the cause of death.  We may also release your medical information to funeral directors, as necessary, to carry out their duties.

INMATES
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the correctional institution or law enforcement official.  This disclosure would be necessary (1) for the institution to provide you with health care; (2) to protect the health and safety of you and others; (3) for the safety and security of the correctional institution.

MILITARY AND VETERANS
We may disclose your PHI as required by military command authorities if you are a member of the armed forces.  We may also release medical information about foreign military personnel to the appropriate foreign military authority.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS
We may disclose your PHI to authorized federal officials so they may provide protection to the President of the United States of America, other authorized persons or foreign heads of state or to conduct special investigations.

AS REQUIRED BY LAW
We may use or disclose your PHI in any other circumstances other than those listed above where we would be required by state or federal law or regulation to do so.

IV. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION THAT REQUIRE YOUR WRITTEN AUTHORIZATION
In general, we will need your specific written authorization on our HIPAA Authorization Form to use or disclose your PHI for any purpose other than those listed above in Section III.  For example, in order for us to send your information to your life insurance company, you would need to sign our HIPAA Authorization Form and tell us what information you would like sent.

We will seek your specific written authorization for at least the following information unless the use or disclosure would be otherwise permitted or required by law as described above in Section III:

• Marketing. We must obtain your written authorization prior to using your PHI to send you any marketing material. We can, however, provide you with marketing materials in a face-to-face encounter, and communicate with about products or services related to your treatment, care management coordination, alternative treatments, therapies or providers without your authorization.
• HIV/AIDS information.  In most cases, we will NOT release any of your HIV/AIDS related information unless your authorization expressly states that we may do so. However, there are certain purposes for which we may be permitted to release your HIV/AIDS information without obtaining your expressed authorization, such as mandatory reporting to the NJ State Department of Health and Senior Services.
• Sexually transmitted disease information.  We must obtain your specific written authorization prior to disclosing any information that would identify you as having or being suspected of having a sexually transmitted disease. However, we may use and disclose information related to sexually transmitted diseases without obtaining your authorization only where permitted by law, including reporting to NJ State Department of Health and Senior Services,  your physician or to health authority, such as a local board of health.
• Tuberculosis Information.  We must obtain your specific written authorization prior to disclosing any information that would identify you as having or being suspected of having tuberculosis (TB). However,   we may use and disclose information related to TB without obtaining your authorization where authorized by law, such as to the Commissioner of the New Jersey State Department of Health and Senior Services.
• Psychotherapy notes.  We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law.  However, there are certain purposes for which we may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.
• Mental Health Information.  We must obtain your specific written authorization prior to disclosing certain mental PHI or information that would identify you as having a mental health condition. However, we may use and disclose information related to mental health without obtaining your authorization only where permitted by law, including for public health purposes such as reporting of child or elder abuse or neglect.
• Drug and alcohol information.  We must obtain your specific written authorization prior to disclosing information related to drug and alcohol treatment or rehabilitation under certain circumstances such as where you received drug or alcohol treatment at a federally funded treatment facility or program. 
• Genetic information.  We must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment or health care operations purposes.  However, we may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law, such as in order to determine paternity as required by a county welfare agency or ordered by a court, to determine the identity of deceased individuals.
• Information related to emancipated treatment of a minor.  If you are a minor who sought emancipated treatment from us, such as treatment related to your pregnancy or treatment related to your child, or a sexually transmitted disease, we must obtain your specific written authorization prior to disclosing any of your PHI related to such treatment to another person, including your parent(s) or guardian(s), unless otherwise permitted or required by law. 

V. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding your PHI we create and/or maintain about you:

RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy your PHI that we maintain. Your right to inspect and obtain a copy extends only to your information contained in the “Designated Record Set”. This includes medical and billing records and any other records that may be used to decisions about your health care.
Under limited circumstances, you may be denied access to a portion of your record if such access is determined to be medically contraindicated.

If we maintain your record in an Electronic Medical Record (EMR), you have a right to request a copy in an electronic format if readily producible.

We may charge you a reasonable fee to cover copying, postage and/or preparation of a summary or other related supplies or expenses. We may also charge for our labor when providing an electronic copy of your records. To inspect and/or receive a copy of your PHI, you must submit your request in writing. Please contact Shore Medical Center Health Information Management (Medical Records) Department.

RIGHT TO REQUEST AN AMENDMENT
You may request we amend or change your PHI maintained by us. We will comply with your request unless:

• We believe the information is accurate and complete.
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the designated record set or otherwise available for inspection.

Requests for amendments must be in writing and provide a reason for the request. Please contact the HIPAA Privacy Office at 609-926-4300.

RIGHT TO AN ACCOUNTING OF DISCLOSURES
You may request an accounting of certain disclosures we have made of your PHI within the period of six (6) years from the date of your request for the accounting.
The first request within a 12-month period will be free of charge.  For additional requests, we may charge you for the costs of providing the accounting.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
To request this accounting of disclosures, please contact Shore Medical Center Privacy Office.

RIGHT TO ADDITIONAL REQUEST RESTRICTIONS
You have the right to request restrictions on uses and disclosure of your PHI, such as:

• For treatment, payment and health care operations,
• To individuals involved in your care or payment related to your care, or
• To notify or assist individuals locate you or obtain information about your condition.

We are not required to agree to your request and we may say “no” if it would affect your care. However, we will grant your request when it relates solely to disclosure of your PHI to a health plan or other payor for the sole purpose of payment or health care operations for a healthcare item or service that you have paid us out-of pocket and in full. To request restrictions, you must make your request in writing to the Shore Medical Center Privacy Office.  In your request, you must include (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to make a written request to receive your PHI by alternative means of communication or at alternative locations.  Please contact the Shore Medical Center Privacy Office. Your request must specify where and how you wish to be contacted. We will not ask you for the reason for your request.  We will accommodate all reasonable requests.

RIGHT TO NOTICE OF BREACH
In accordance with law, we will notify you if there is a breach of your unsecured Protected Health Information and inform you of what steps you need to take to protect yourself.

RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this Notice.  You may ask us to give you a copy of this Notice at any time, even if you have agreed to receive this notice electronically. Please contact the Privacy Office to obtain a paper copy of this Notice.

VI. CHANGES TO THIS NOTICE
We reserve the right to change this Notice and make the new provisions applicable to your entire PHI – even if it was created prior to the change in the Notice.  We will post a copy of the current Notice in the medical center.  The Notice will contain the effective date on the upper right-hand corner of the first page of this Notice.
In addition, each time you register at or are admitted to the medical center for treatment or health care services as an inpatient or outpatient, we will make available a copy of the current Notice in effect.

VII. COMPLAINTS
If you believe your privacy rights have been violated, or you disagree with a decision we made about access to your PHI, you may contact and file a written complaint with the Shore Medical Center Privacy Office. You will not be penalized for filing a complaint.

Shore Medical Center Privacy Office
100 Medical Center Way
Somers Point, NJ  08244

You may also file a written complaint with the Office for Civil Rights at:
U.S. Department of Health and Human Services - Jacob Javits Federal Building
26 Federal Plaza, Suite 3312, New York, NY 10278

VIII. ELECTRONIC NOTICE
This Notice of Privacy Practices is also available on our web page at www.shoremedicalcenter.org.