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.
The Health Insurance Portability and Accountability Act of 1996 and its implementing rules and regulations (HIPAA) requires that we provide this notice to you. The terms of this notice apply to all of Deborah Heart and Lung Center’s facilities, locations, programs, employees, agents, and volunteers (collectively, DEBORAH®). It also applies to health care providers not employed by Deborah but on our medical staff, such as independent consulting physicians, auxiliary and other physicians who may provide care to you while at DEBORAH (“Independent Practitioners”), as well as medical residents, interns and other individuals participating in medical education.
This Notice of Privacy Practices describes how DEBORAH may use and disclose your Protected Health Information (your “health information”) that DEBORAH may collect, create, or maintain, in any format, whether paper or electronic. In general, DEBORAH may only use and disclose your health information in the ways described in this Notice. This includes use and disclosure of your health information in connection with clinically integrated networks and organized systems of health care (“OHCAs”) of which DEBORAH is a part, and through which it conducts certain joint activities, including:
- DEBORAH conducts certain joint activities in an OHCA with Deborah Cardiovascular Group, P.C., d/b/a Deborah Specialty Physicians (“DSP”), a specialty physician practice with offices in Atlantic, Burlington, Mercer and Ocean Counties (the “DSP OHCA”). The purpose of the DSP OHCA is to improve and coordinate care for patients of both DEBORAH and DSP. The DSP OHCA allows DEBORAH to use and/or disclose your health information to and from DEBORAH and DSP and their providers for your treatment when you are receiving care by/at DSP, payment for your care provided by DSP, or for healthcare operations, which may include joint DSP-DEBORAH activities such as quality improvement, and risk management activities. DSP providers may also be on DEBORAH’s medical staff, as described below.
- DEBORAH also conducts certain joint activities in an OHCA with Heart Care Specialists (“HCS”), a physician practice associated with Capital Health System (the “HCS OHCA”). The purpose of the HCS OHCA is also to provide a focus on improving patient care. The HCS OHCA may use and/or disclose your health information for treatment, payment or healthcare operations at both DEBORAH and HCS offices, which disclosure may be for integrated information system management, health information exchange, financial and billing services, insurance, quality improvement, and risk management activities, among others.“
This Notice also describes how Independent Practitioners may access, use and disclose your health information when providing services to you at DEBORAH. There are two general categories of Independent Practitioners from which you may receive care while a patient at DEBORAH. These Independent Practitioners are not employees, nor agents, of DEBORAH and they remain solely responsible for the care and services they provide to you at DEBORAH. You, or your insurance company, may receive a separate bill from these Independent Practitioners for the services they provide to you at DEBORAH.
- Independent Practitioners that provide certain auxiliary and consulting physician services at DEBORAH and/or to DEBORAH patients on behalf of DEBORAH. DEBORAH requires these Independent Practitioners to comply with applicable DEBORAH policies and medical staff policies when providing services at DEBORAH, including policies protecting the privacy and security of your health information and the terms of this Notice.
- Independent Practitioners, such as your primary care physician or specialists, who do not provide care to you while at DEBORAH but who may seek to review your medical record for information about the services you receive while you are a patient at DEBORAH. DEBORAH requires these Independent Practitioners to comply with DEBORAH’s medical staff and medical record policies when they access your information.
For a list of health care providers who provide care at DEBORAH, including our employees and Independent Practitioners, please visit our website at www.deborah.org or contact our Medical Staff at 609-893-1200, ext. 5800. A paper copy is available upon request.
DEBORAH is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices, and your rights with respect to your health information. DEBORAH is required to abide by the terms of this Notice of Privacy Practices. If you have questions about any part of this Notice or if you want more information about the Privacy practices of DEBORAH, please contact: Director of Compliance and Privacy at 609 893-1200, extension 5820.
Revision and Effective Date of This Notice: September 10, 2021
Originally Adopted: April 14, 2003
I. How DEBORAH May Use or Disclose Your Health Information
DEBORAH collects health information from you and stores it in a medical chart and on DEBORAH computer systems. This is your medical record. The medical record is the property of DEBORAH, but you have rights with respect to the information in the medical record that is about you. DEBORAH protects and takes seriously the privacy of your health information. DEBORAH will notify you in the event a breach occurs of your unsecured health information and inform you what steps you may need to take to protect yourself.
Where we are permitted to use or disclose your health information as described in this Notice, we may do so verbally or on paper or by fax. We may also do so electronically, including through one or more health information exchange organizations (“HIO”). These HIOs may include the CommonWell Health Alliance, Carequality, and NJHIN, among others. An HIO will allow your participating health care providers, your health plans and other authorized individuals or entities to electronically access, use and disclose your health information such as test results, medication history and other health information for your treatment, payment for care provided to you, health care operations and other permitted purposes by searching an electronic database linked to our records. If we do share your health information through an HIO, you will be provided with information about the HIO and the opportunity to opt-out of participation in such HIO. If you decide to opt-out of the HIO, we may continue to use and disclose your health information through other traditional mechanisms (i.e., paper, electronically or fax) as described and permitted by this Notice.
State and federal law generally permit DEBORAH to use or disclose your health information for the following purposes:
- Treatment. Information may be used and disclosed for patient care activities delivered in the inpatient and outpatient setting, as well as for clinically necessary referrals to specialists located outside of DEBORAH. For example, a nurse may access your medical record or query your medication history to administer medications. Likewise, DEBORAH may permit other health care providers who are also involved in your care, such as anesthesiologists, interventional cardiologists, podiatrists and other physicians with which DEBORAH has contracted with, or who provide services to our patients to access your health information for treatment purposes. We may also disclose certain health information to your primary care provider or specialists related to your treatment and coordination/management of care, as well as to our residents, fellows, interns and other health care providers participating in medical education at DEBORAH. Likewise, DEBORAH may permit access to, or disclose your health information to DSP and HCS related to the treatment activities of the DSP and HCS OHCAs. DEBORAH may also receive health information from your other health care providers and pharmacies for treatment purposes.
- Payment. We will provide information to your insurance companies so they can pay DEBORAH for services provided to you. For example, we may contact your insurance company to determine whether you are eligible for certain services or benefits. We may provide a bill to your insurance company with the services rendered to you so we can be paid for the services. We may also share certain information with other health care providers who provide you care so they can receive payment from your insurance company, or from you, for the services they provide. Likewise, DEBORAH may permit access to, or disclose, your health information to DSP and HCS related to the treatment activities of the DSP and HCS OHCAs.
- Regular Health Care Operations. During, and following, the course of your treatment at DEBORAH it may be necessary to share your health information with other care givers and parties to help with the normal healthcare operations of DEBORAH, including assessment, coordination and improvement of patient care, physician evaluations and reviews, and education of DEBORAH employees or medical residents. For example, the quality department may access your medical record to create learning tools relating to best practices or process improvements. DEBORAH may also need to share your health information with other members of the DEBORAH staff or outside contractors, vendors, consultants and agents who assist the hospital in its general administrative and business functions, such as to DEBORAH’s attorneys or accountants so that they can provide legal services or conduct auditing functions for DEBORAH, or to DEBORAH’s billing, software and other vendors and business associates providing other services for DEBORAH. Under certain circumstances, we may also share and receive your health information with and from other health care providers and the DSP and HCS OHCAs to help coordinate and manage your care, for quality improvement and assessment and similar activities.
- Directory. We may list in our “directory” your name and general condition, your hospital location/room, as well as your religious affiliation. Other than your religious affiliation, this information may be provided to people who call or visit and ask for you by name. This information may also be provided to members of the clergy. You ask that your information be removed from our directory. If you want to be removed, you must tell us.
- Notification and Communication with Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
- Required by Law. As required by law, we may use and disclose your health information to the extent necessary for DEBORAH to comply with such law.
- Public Health. As required or permitted by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; reporting to state immunization registries or to those required by law to have access to immunization records, and reporting disease or infection exposure.
- Health Oversight Activities. We may disclose your health information to agencies during the course of audits, investigations, inspections, licensure, accreditation and other proceedings.
- Judicial and Administrative Proceedings. We may disclose your health information for an administrative or judicial proceeding, providing certain procedures are followed.
- Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
- Deceased Person Information. We may disclose your health information to coroners, medical examiners and funeral directors. We may also disclose your health information to those family members, friends or other individuals involved in your care or payment for such care before your death.
- Organ Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
- Research. We may disclose your health information to researchers conducting research approved by an Institutional Review Board.
- Public Safety. We may disclose your health information to appropriate persons to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
- Specialized Government Functions. If necessary, we may disclose your health information for military and national security purposes, such as protection of the President.
- Worker’s Compensation. We may disclose your health information to comply with worker’s compensation laws.
- Appointment Reminders. We may contact you to provide appointment reminders or to give information about other treatments or health-related benefits and services that may be of interest to you.
- Fundraising. Deborah Hospital Foundation may contact you about fundraising activities for DEBORAH. You have the right to opt out these fundraising communications at any time.
- Change of Ownership. In the event DEBORAH is sold or merged with another organization, your health information/record will become the property of the new owner.
- Right to receive Notice of Privacy Breach. You have the right to receive written notification if DEBORAH discovers a breach of unsecured protected health information involving your health information. Breach means the unauthorized acquisition, access, use, or disclosure of protected health information which compromises the security or privacy of information. The Notice will include a description of the breach, health information involved, steps we have taken to mitigate the breach, and actions that you may need to take in response to the breach.
II. When DEBORAH May Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, DEBORAH will not use or disclose your health information without your written authorization. If you do authorize DEBORAH to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time, except to the extent that DEBORAH has already relied upon your authorization, by contacting the Director of Compliance, Privacy and Auditing.
Except as otherwise permitted or required by law, DEBORAH will generally ask for your written authorization prior to (1) use or disclosure of any psychotherapy notes, (2) use or disclosure of your health information for marketing purposes, or (3) use or disclosure of your health information where DEBORAH would receive something of value in exchange for the information (a “sale” of information).
In certain circumstances, DEBORAH may be required under State or other law or regulation to obtain your written authorization. For certain categories of your health information that are considered “sensitive” and subject to more stringent protections, we will comply with applicable State or federal laws when disclosing sensitive information, including, but not limited to, HIV/AIDS, Genetic, Sexually Transmitted Diseases and Tuberculosis information, information related to emancipated care received by a minor, as well as Drug/ Alcohol and Mental Health/Behavioral information originating from certain licensed facilities.
III. Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your health information, such as for treatment, payment or health care operations purposes. However, DEBORAH is not required to agree to a restriction that is requested unless you request a restriction on disclosure to your health plan(s) for payment or health care operations purposes and such disclosure relates solely to a health care item or service for which you have paid DEBORAH in full and out of pocket (“out of pocket restriction”). DEBORAH will honor any out of pocket restriction unless the requested disclosure is required by law.
- You have the right to request to receive your health information through a reasonable alternative means or at an alternative location.
- You have the right to inspect and copy your health information that DEBORAH maintains in a Designated Record Set, including an electronic copy of this health information. DEBORAH may charge a reasonable cost-based fee to provide you with copies of your health information.
- You have a right to request that DEBORAH amend your health information that DEBORAH maintains in a Designated Record Set if you believe it is incorrect, inaccurate or incomplete. DEBORAH is not r equired to change your health information if it believes it is correct, accurate and complete, or under certain other circumstances. If that is the case, DEBORAH will provide you with information about DEBORAH’s denial, and how you can disagree with the denial.
- You have a right to request and receive an accounting of disclosures of your health information made by DEBORAH for a period of six (6) years from the date on which such disclosure was made. DEBORAH may charge a reasonable cost-based fee to provide you with an accounting where you request more than one (1) accounting in a given calendar year. DEBORAH is not required to account for certain types of disclosures of health information.
- You have the right to a paper copy of this Notice of Privacy Practices, even if you have already received an electronic copy.
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 Director of Compliance, Privacy and Auditing, 200 Trenton Road, Browns Mills, New Jersey 08015, (609) 893-1200, extension: 5820.
IV. Changes to this Notice of Privacy Practices
DEBORAH reserves the right to amend this Notice of Privacy Practices at any time in the future. If an amendment is made, DEBORAH will promptly display and make available the revised Notice of Privacy Practices as of the effective date of the amendment.
Complaints about this Notice of Privacy Practices, or how DEBORAH handles your health information, should be directed to Deborah Heart and Lung Center, Attn: Director of Compliance, Privacy and Auditing, 200 Trenton Road, Browns Mills, New Jersey 08015, (609) 893-1200, extension: 5820.
You may also complain to the Department of Health and Human Services by contacting the Regional Manager, Office for Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312, New York New York 10278, (800) 368-1019. DEBORAH will not retaliate or discriminate against you for filing a complaint.
VI. Electronic Notice
This Notice of Privacy Practices is also available on the Deborah web page at www.DemandDeborah.org.
Last Updated: September 2021