HIPAA 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.

Download our Notice of Privacy Practices in the following languages: English | Albanian | Arabic | Greek | Gujarati | Haitian Creole | Hindi | Korean | Portuguese | Russian | Simplified Chinese | Spanish | Traditional Chinese | Vietnamese

If you have any questions about this notice, please contact the appropriate health care institution listed on the schedule at the end of this notice.

This notice describes the practices of:

• All Beth Israel Lahey Health covered entities and organized health care arrangement participants ("BILH Entities"). A list of these entities can be found on the schedule at the end of this notice. All these entities, sites and locations may share medical information with each other for treatment, payment, or health care operations purposes described in this notice.
• Any health care professional authorized to enter information into your health record on behalf of these entities.
• All departments and units of these entities.
• Any member of a volunteer group helping with your care.
• All employees, staff and other personnel of these entities.

This notice describes the ways we may use and disclose your medical information. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.

We are required by law to:

• make sure medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you;
• notify you if there is a breach of your unsecured personal health information; and
• follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information About You

The following describes different ways that we are permitted to 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 your medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other health care personnel who are involved in caring for you at BILH Entities or outside BILH Entities. Different departments and providers also may share medical information about you in order to coordinate the different services/treatments you need, such as prescriptions, laboratory work, and x-rays. We may also disclose medical information about you to people who may be involved in maintaining your health or well-being, such as family members, friends, home health services, support agencies, clergy, medical equipment suppliers, or others who provide services that are necessary for your well-being.

For Payment

We may use and disclose your medical information so that the treatment and services you receive at BILH Entities may be billed and payment may be collected from you, an insurance company, or a third party. We may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. We may also give information to someone who helps pay for your care.

For Health Care Operations

We may use and disclose your health information for business tasks necessary for our operations, including, for example, to improve the quality of care, train staff and students, provide customer services, or conduct any required business duties to better serve our patients and community. Also, we may share your medical information with others we hire to help us provide services and programs.

Other Examples of Health Care Operations

Appointment Reminders

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives

We may use and disclose medical information to tell you about or recommend possible treatment options or health related benefits that may be of interest to you.

Fundraising Activities

We may use limited information about you (including demographic information, date of birth, dates of service, department of service, treating physician or outcome information) to contact you in an effort to raise money for BILH Entities and their operations. If you do not want us to contact you as part of our fundraising efforts, please contact the appropriate fundraising office of the health care institution listed on the attached schedule.

Hospital Directory

We may include certain limited information about you in the hospital directory while you are an inpatient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., good, fair, 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 name may be given to a member of the clergy, even if they do not ask for you by name. If you do not want to be listed in the hospital directory please contact your nurse. In disaster situations, those involving multiple casualties, we may release general information, such as: the hospital is treating four individuals from the accident.

Research

We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

As Required By Law

We will disclose your medical information 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 your medical information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be only to someone able to help prevent the threatened harm.

Special Situations

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, status and location.

Organ and Tissue Donation

If you are a potential 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, as necessary, to facilitate organ or tissue donation and transplantation.

Military and Veterans

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

Workers' Compensation

We may release your medical information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks

We may disclose, when requested, your medical information 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 abuse and/or neglect of a child, elder or disabled person;
• 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.

Health Oversight Activities

We may, when requested, disclose your medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, certifications, 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 your medical information in response to a court order. Under certain circumstances, we may also disclose your medical information in response to a subpoena or other lawful process, but we will do so only if efforts have been made to tell you about the request or to obtain an order protecting the information requested or if you or a court have provided written authorization.

Law Enforcement

We may release your medical information if asked to do so by a law enforcement official, if permitted by law:

• 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 BILH Entity; and
• 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.

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 to funeral directors or designees as necessary to carry out their duties.

National Security and Intelligence Activities

If permitted by law, we may release your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities, authorized by law.

Protective Services for the President and Others

If permitted by law, we may release medical information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, if permitted by law.

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, under certain circumstances if permitted by law. 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 institution.

Your Rights Regarding Medical Information About You

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

Right To Inspect and Obtain a Copy

You have the right to inspect and obtain a copy of your medical information that may be used to make decisions about your care. This request usually includes medical and billing records but may not include psychotherapy notes.

To inspect and obtain a copy of your medical information that may be used to make decisions about you, you must submit your request in writing to the appropriate BILH Entity listed on the attached schedule at the end of this notice. 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 obtain a copy of psychotherapy notes in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the BILH Entity 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.

Home Health patients have additional rights to receive their records at no charge, upon request at their next home visit or in an expedited manner.

Retention of Records

State law requires that we retain hospital records for a minimum of twenty years from the date last seen. The record may be destroyed after twenty years without activity, but must be destroyed in a secure manner, protecting your information from unauthorized disclosure. Ancillary records, such as radiologic films, scans, other imaging records, raw psychological testing data, electronic fetal monitoring strips, electrocardiogram tracings, electroencephalographs, and other sample tracings generated to report the results of a test are interpreted in reports in the legal medical record, and may be destroyed after a minimum of five years following the date of service. Physician office records may be destroyed 7 years after your last date of service or if the patient is a minor, records may be destroyed after 7 years or until the minor reaches the age of 18, whichever is longer.

Right To Amend

For hospital records, please send your request to the appropriate hospital listed at the end of this notice. To request an amendment of your physician office record, contact your physician's office directly. Requests for amendment must be made in writing and give the reason you are requesting the amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

• Was not created by us, or 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 us;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right To Request an Accounting of Disclosures

You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of your medical information for which an authorization was not obtained, or which were not made for purposes of treatment, payment, or healthcare operations.

To request this list or accounting of disclosures, you must submit your request in writing to the appropriate BILH Entity listed at the end of this notice. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. 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.

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, such as a family member or friend.

Except as noted below, we are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you. By law, we must agree to your request to restrict disclosure of your medical information to a health plan if the disclosure is (1) for the purpose of carrying out payment or health care operations, (2) is not otherwise required by law, and (3) for an item or service you have paid for in full, out-of-pocket.

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 contact you only at work or by mail.

To request confidential communications, you must make your request in writing to the appropriate BILH Entity listed on the attached schedule at the end of this notice. We will not ask you the reason for your request. At our discretion, we will accommodate all reasonable requests. Your 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. You may ask us at any time to give you a copy of this notice. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice from the appropriate BILH Entity listed on the attached schedule at the end of this notice.

Download our Notice of Privacy Practices here.

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. The notice will contain the effective date on the first page, in the top right-hand corner.

In addition, each time you register or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, a copy of the notice currently in effect will be available at your request.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the BILH Entity by contacting the appropriate BILH Entity listed on the attached schedule at the end of this notice or you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 877-696-6775, or filing a complaint online. All complaints with the BILH Entities must be submitted in writing.

You will not be penalized for filing a complaint.

The Massachusetts Health Information HIway (Mass HIway)

We participate in the Mass HIway, a statewide electronic health information exchange. The Mass HIway allows doctors' offices, hospitals, laboratories, pharmacies, skilled nursing facilities, and other healthcare organizations a way to securely and seamlessly transmit health information electronically. We will obtain your consent to the use the Mass HIway as required by state law.

Special Confidentiality Protections for Treatment Records from Substance Use Disorder Programs

If you have received treatment, diagnosis, or referral for treatment from our substance use disorder programs, the confidentiality of drug or alcohol use records is protected by federal law and regulations. As a general rule, we may not tell a person outside the programs that you attend any of these programs, or disclose any information identifying you as someone who sought or received substance use disorder treatment unless:

• You authorize the disclosure in writing; or
• the disclosure is permitted by a court order; or
• the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation purposes.

You should also know:

• A violation by us of the federal law and regulations governing drug or alcohol use may be a crime.
• Suspected violations may be reported to the United States Attorney at 617-748-3100.
• Information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime is not protected.
• These laws do not protect any information about suspected child abuse or neglect from being reported to appropriate authorities.

For more information see 42 U.S.C. Section 290dd-2 and 42 C.F.R., Part 2.

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.

Notice of Non-Discrimination

BILH Entities comply with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.