SOMERSET MEDICAL CENTER

NOTICE OF PRIVACY PRACTICES

 

Effective Date: April 1, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact:

Privacy Officer
Somerset Medical Center
110 Rehill Avenue
Somerville, New Jersey 08876-2598
Phone: 908-685-2200

WHO WILL FOLLOW THIS NOTICE

This notice describes Somerset Medical Center’s practices and that of:

• any health care professional authorized to enter information into your hospital chart
• all departments and units of Somerset Medical Center
• any member of a volunteer group we allow to help you while you are in the hospital
• all employees, staff, and other Somerset Medical Center personnel
     

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.  We create a record of the care and services you receive at Somerset Medical Center.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by Somerset Medical Center, whether made by hospital personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information.  We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private
• give you this notice of Somerset Medical Center’s legal duties and privacy practices with respect to medical information about you
• follow the terms of the notice that are currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information.  For each category of uses or disclosures we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed, however, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment.   We may use medical information about you to provide you with medical treatment or services.   We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at Somerset Medical Center. 
For example, a doctor treating you for a broken leg may need to know if you have diabetes, since diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals.  Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays.  We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy, or others providers of care.

For Payment.  We may use and disclose medical information about you so that the treatment and services you receive at Somerset Medical Center may be billed and payment may be collected from you, an insurance company, or a third party.   For example, we may need to inform your health plan about a surgery you had at Somerset Medical Center so that your health plan will cover your medical costs or reimburse you for the surgery.  We may also tell your health plan about treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations.   We may use and disclose medical information about you for hospital operations.   These uses and disclosures are necessary to run Somerset Medical Center and make sure that all of our patients receive quality care.  For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.  We may also combine medical information about many hospital patients to decide what additional services Somerset Medical Center should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes.  We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care we provide.  We may remove information that identifies you from this set of medical information so that  others may use it to study health care and health care delivery without learning who specific patients are.

Appointment Reminders.   We may use and disclose medical information to remind you that you have an appointment for treatment or medical care at Somerset Medical Center.

Treatment Alternatives.   We may use and disclose medical information to tell you about or recommend treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services.   We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Fundraising Activities.   We may use medical information about you to contact you in an effort to raise money for Somerset Medical Center and its operations.   We may disclose medical information to a foundation related to Somerset Medical Center so that the foundation may contact you for fundraising efforts.  We only would release contact information, such as your name, address, and phone number and the dates you received treatment or services at Somerset Medical Center.  If you do not want to be contacted or fundraising reasons, you must notify the Privacy Officer in writing at the address listed above.

Hospital Directory.   We may include certain limited information about you in the hospital directory while you are a patient at Somerset Medical Center.   This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.), and your religious affiliation.  The directory information, except for your religious affiliation, may also be released to people who ask for you by name.  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 is so your family, friends, and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care.   We may release medical information about you to a friend or family member who is involved in your medical care.   We may also give information to someone who helps pay for your care.  We may also tell your family or friends your condition and that you are in Somerset Medical Center.  In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition and location.

Research.   Undercertain circumstances, we may use and disclose medical information about you for research purposes.   For example, a research project may compare one medication to another in the health and recovery of patients with the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy.  Before Somerset Medical Center uses or discloses medical information for research, the project will have been approved by a panel called an Institutional Review Board (“IRB”).  The IRB is made up of physicians, nurses, social workers, and community representatives.  During the research approval process, we may disclose medical information about you to people preparing to conduct a research project.  For example, medical information may be used to help physicians look for patients with specific medical needs, so long as the medical information they review does not leave Somerset Medical Center.  We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are.

As Required By Law.   We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety.   We may use and disclose medical information about you when necessary to prevent a serious threat to the health and safety of you, another person, or the public.   Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and Tissue Donation.   If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank.

Military and Veterans.   If you are a member of the armed forces, we may release medical information about you as required by military command authorities.   We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation.    We may release medical information about you for workers’ compensation or similar programs.   These programs provide benefits for work-related injuries or illness.

Public Health Risks.   We may disclose medical information about you for public health activities.   These activities generally include the following:

• to prevent or control disease, injury, or disability;to report births and deaths;to report child abuse or neglect
• to report reactions to medications or problems with products   to notify people of recalls of products they may be using
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities.   We may disclose medical information to a health oversight agency for activities authorized by law.   These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes.   If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order.   We may also disclose medical about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request and to allow you to obtain an order protecting the information requested.

Law Enforcement.   We may release medical information if asked to do so 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 criminal conduct
• about criminal conduct at the hospital
• in emergency circumstances to report a crime, its location, possible victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors.   We may release medical information to a coroner or medical examiner.   This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release medical information about patients of Somerset Medical Center to funeral directors, as necessary.

National Security and Intelligence Activities.    We may release medical information about you to authorized federal officials for intelligence, counterintelligance, and other national security activities authorized by law.

Protective Services for the President and Others.  We may disclose medical information about you to authorized federal officials so they may provide protection to the President, authorized persons, heads of state, or to conduct special investigations.

Inmates.   If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.    This release would be 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 facility.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy.   You have the right to inspect and copy medical information that may be used to make decisions about your care.   Usually this includes medical and billing records, but does not include psychotherapy notes.  To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the hospital will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

Right to Amend.   If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.   You have the right to request an amendment for as long as the information is kept by or for Somerset Medical Center.  To request an amendment, your request must be made in writing and submitted to the Privacy Officer.  In addition, you must provide a reason that supports your request.  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

• 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 medical information kept by or for Somerset Medical Center
• is not part of the information that you would be permitted to inspect and copy
• is accurate and complete.

Right to an Accounting of Disclosures.  You have the right to an “accounting of disclosures.”   This is a list of the disclosures we made of medical information about you.  To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer.  Your request must state a time period, which may not be long than six years and may not include dates before February 26, 2003.  Your request should indicate in what form you want the list (e.g. electronically or via hard copy).  You are entitled to a free list every 12 months.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost and you may withdraw or modify your request before any costs are incurred.

Right to Request Restrictions.   You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.   For example, you could ask that we not use or disclose information about a surgery you had.  We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.  To request restrictions, you must make your request in wring to the Privacy Officer.  In your request, you must tell us (1) what information you want limited; (2) whether you want to limit our use, disclosure, or both; and (3) to whom the limits should apply, such as limiting disclosures to your spouse.

Right to Request Confidential Communications.   You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.   For example, you can ask that we only contact you at work or by mail.  To request confidential communications, you must make your request in writing to the Privacy Officer.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  The request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice.   You have the right to a paper copy of this notice at any time. In addition, you may access a copy of this notice at Somerset Medical Center’s website, www.somersetmedicalcenter.com.   To obtain a paper copy of this notice, contact the Privacy Officer.

CHANGES TO THIS NOTICE

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in the hospital as well as on our website, www.somersetmedicalcenter.com.  The notice will contain on the first page, in the top right-hand corner, the effective date.  In addition, each time you register at or are admitted to Somerset Medical Center for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Somerset Medical Center or with the Secretary of the Department of Health and Human Services.   To file a complaint with Somerset Medical Center, contact the Privacy Officer.   All complaints must be submitted in writing.  You will not be penalized in any way for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.   If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.   If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.