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We
Honor
Your
Trust
Your privacy and protection of your personal health information have always been of great importance to everyone who works at Massachusetts General Hospital. We are committed to providing you with the highest quality health care and to forming a relationship with you built on trust. This trust can only be built on our commitment to respecting the privacy and confidentiality of your health information.
On April 14, 2003, the federal Office of Civil Rights will be enforcing new rules to ensure this trust between patients and their healthcare providers. As part of those new rules, healthcare providers will be required to obtain your signature in acknowledgement of how the hospital/provider uses and shares your personal health information.
Today, we are giving out this booklet and a form that will meet this requirement. The booklet is the Massachusetts General Hospital’s Privacy Notice, which is a very detailed explanation of how your personal health information is used and secured here at MGH. There is nothing new to how we use your information—this is merely telling you how we run our day to day activities in caring for patients. What are new are some additional patient rights in regard to your personal health information.
The accompanying form is the Acknowledgement of Receipt of Privacy Notice. This form will be presented to every patient along with the Privacy Notice. We will ask for your signature and make this a part of your healthcare record.
We appreciate your time and understanding in helping us meet the new federal regulations. Please review the Notice at your convenience and feel free to contact the Privacy Office at (617) 726-2465 to ask any questions. Thank you.
MASSACHUSETTS GENERAL
HOSPITAL NOTICE FOR
USE AND SHARING OF PROTECTED HEALTH
INFORMATION
Massachusetts General Hospital is a member
of an integrated
health care system known as Partners HealthCare and
Partners Community HealthCare.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
The word “Partners” in this Notice includes Massachusetts General Hospital and all organizations listed at the end of this notice.
This Notice is being given to you because federal law gives
you the right to be told ahead of time about:
• how
Partners will handle your medical information
• Partners’
legal duties related to your medical information
• your rights with regard to your medical information.
Please note that treatment at McLean Hospital and/or at certain designated Substance Abuse Facilities provides you with additional protections, as noted in bold italics throughout this Notice.
A. HOW WE MAY USE AND DISCLOSE (SHARE) YOUR PROTECTED
HEALTH
INFORMATION
When you need health care, you give information about yourself and your health to doctors, nurses, and other health care workers and staff. This information, along with the record of the care you receive, is “protected health information” (or “health information”). This information is kept in a paper form such as your medical record and in an electronic form on the computer.
Partners uses your health information within its system, and shares your health information outside its system in order to give you excellent medical care. Partners uses and shares your health information for other reasons that can include medical research and training new health care workers. For example, Partners may share your health information with outside health care providers for purposes such as treatment or research; in some cases, these providers have a specific relationship with Partners, such as the adult cancer care program with The Dana Farber Cancer Institute (Dana Farber/Partners Cancer Care) and physicians who have outside private practices but also occasionally work at a Partners hospital. Also, other outside parties who receive your information in order to perform services on Partners’ behalf (“business associates”) must also take steps to keep your health information private.
This Notice will tell you how Partners uses and shares your health information for these and other purposes. It will also tell you when we need to get your specific permission to do so.
1. Treatment, Payment, and Health Care Operations
Except where prohibited by Massachusetts state or federal laws (see section 4), Partners may legally use and share your health information for treatment, payment, and health care operations. We do not need to ask for your specific permission to do these things, as explained below:
Treatment
Partners health care providers will use and share your health information to provide and manage your health care and related services. For example, your primary care doctor may refer you to a specialist such as a radiologist or surgeon. The specialist may tell you that you need to be admitted to the hospital for treatment or surgery. All of the doctors in this example, whether they are in the Partners system or not, will share medical information about you. This is to coordinate your care before, during and after you go into the hospital. Partners will share information with other third parties, such as home health agencies, visiting nurses, rehabilitation hospitals, and ambulance companies. It will also share information with those who treated you before you went into the hospital and with those who will treat you in the future. This helps to make sure that everyone caring for you has the information they need.
McLean Hospital and dedicated Substance Abuse Facilities and/or providers will not share information with other Partners entities and/or health care providers without an authorization signed by you to release information.
Payment
Partners will use and share your health information to bill and collect payment for the health care services it gives to you. For example, if you have health insurance, your health care provider will share your medical information with the insurance company or government agency. The insurance company uses the information to tell if you are eligible for benefits or if the services you received were medically needed.
Health Care Operations
Partners may use and share your health information for activities
that are known as health care operations. These are activities that are needed
to operate its facilities and carry out its mission. Some of the information
is shared with outside parties who perform these health care operations or
other services on behalf of Partners (“business associates”).
These business associates must also take steps to keep your health information
private. Examples of activities that make up health care operations include:
• monitoring the quality of care and making improvements
where needed
• making sure health care
providers are qualified to do their jobs
• reviewing medical records
for completeness and accuracy
• meeting standards set
by regulating agencies; such as, Joint Commission of Accreditation
• teaching health professionals
• using outside business
services; such as, transcription, storage, auditing, legal or other consulting
services
• giving general services
to patients
• storing your health information
on computers
• managing and analyzing
medical information
Also, Partners may use your health information to contact you:
• at the
address and telephone numbers you give to us (including leaving messages at
the telephone numbers): about scheduled or cancelled appointments,
registration/insurance updates, billing or payment matters,
pre-procedure assessment or test results.
• with information about
patient care issues, treatment choices and follow up care instructions.
• with other health-related
benefits and services that may be of interest to you.
• to raise funds to support
the Partners system and its missions of excellence, provided, however, that
such information is limited to demographic information only, such as name,
address, phone number, age, or gender.
2. Uses and Disclosures (Sharing) of Your Health Information for Other Purposes
Partners may legally use and/or share your health information with others in the following areas without your specific permission:
• For research that is approved
by a Partners Research Committee when written permission is not required
by federal or state law. This also may include preparing for research or telling
you about research studies in which you might be interested.
• As required by state and
federal laws and regulations
• For public health activities,
including required reports to the state public health and child protection
authorities, and to agencies such as cancer registries and the federal Food
and Drug Administration
• With regard to elder victims
of abuse and neglect and in some instances to disabled victims of abuse
or neglect
• For health oversight activities
• For legal and administrative
proceedings
• For law enforcement purposes
under specific conditions such as reporting when someone is the victim
of a crime.
• With regard to people
who have died, to coroners, medical examiners and funeral directors
• For organ, eye or tissue
donation at death
• To avert a serious threat
to health or safety
• For specialized government
operations
• As authorized by and as
necessary to comply with workers compensation laws
3. Uses and Disclosures (Sharing) You May Ask be Limited, or Request Not Be Made
Patient Directories
If you are admitted to the hospital, your name, room location, general condition, and religion may be listed in that hospital’s directory (information desk). This will be shared with members of your family, friends, members of the clergy, and to others who ask for you by name. You may ask to have your name taken off the directory list. You may also ask to restrict the information that is given out about you. If you are in an emergency situation and are not able to make your wishes known, we will put this information in the directory if we think it is in your best interest. We will not put the information in the directory if you have been admitted to the hospital before and asked that it not be shared.
McLean Hospital does not have a patient directory and will not give out any information regarding your care. Dedicated Substance Abuse Facilities also will not release any directory information without your specific authorization.
Disclosures to Family, Friends or Others
• Partners
may share relevant health information about you with a family member or other
person close to you if they are involved in your care or
payment for your care.
• Partners
may use or share your health information to notify a family member or other
person responsible for you of your location, general medical condition or
death.
• If
you are present and are able to make health care decisions, we will try to
find out if you want us to share this information with your
family members or others. If you are in an emergency situation
and not able to make your wishes known, we will use our best judgment to decide
whether to share information. If it is thought to be in
your best interest, we will only share information that
others really need to know.
• Partners
also may use or share your health information with a public or private agency
assisting in disaster relief. This is to coordinate efforts to
notify someone on your behalf. If we can reasonably do so while
trying to respond to the emergency, we will try to find out if you do want
us to share this information.
McLean Hospital and dedicated Substance Abuse Facilities/Providers will not give out any information to family or friends without an authorization signed by you.
4. Uses and Disclosures (Sharing) of Information that Require Your Written Permission (Authorization)
Massachusetts state or federal laws require that we obtain your written permission before using or disclosing the information listed below:
• Sharing
information about genetic testing (as defined by state law) or genetic test
results
• Sharing information about
HIV testing or test results
• Sharing information from
substance abuse rehabilitation treatment programs
• Sharing information about
treatment for sexually transmitted diseases
• Using and sharing health
information for research, research preparation, or recruitment, when the appropriate
Partners Human Research Committee determines this is required under federal
and state laws
• Information which state
law recognizes as “privileged” (sensitive) information can only
be shared in administrative and judicial proceedings if
you give written permission.
• Privileged (sensitive)
information includes information that relates to domestic violence counseling,
sexual assault counseling, confidential communications between
a patient and a social worker, or confidential details of
psychotherapy (from a psychiatrist, psychologist, or licensed mental health
nurse clinical specialist);
• such proceedings may include
civil or criminal trials and their preliminary proceedings, or hearings before
a state, county or local administrative agency
• Using and sharing psychotherapist
notes (notes maintained outside of the medical record for the therapist’s
own use); however, specific permission is not required for use or sharing
of these notes for your therapist to treat you, for training
programs, for legal defense in an action you bring, or for
oversight of the therapist
• Using information regarding
diagnosis, nature of service and treatment information to raise funds to
support the Partners system and its missions of excellence
Note: If you have given permission for your medical information in the above
categories to be used or shared, you may withdraw your permission in writing
at any time except to the extent that the providers have already acted on
it
B. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION AND HOW TO EXERCISE THEM
The Right to Ask for Limits on the Use and Sharing of Your Health Information.
You have the right to ask for restrictions on the use and sharing of your health information for treatment, payment or health care operations. You can also ask for restrictions on using this information to notify you about appointments, etc.
Partners is not required to agree to your request. If we do, we must put the restriction in writing and abide by it except if you need to be treated in an emergency. You may not ask us to restrict uses and sharing of information that we are legally required to make.
The Right to Ask that Your Health Information be Communicated to you
in a Confidential Manner.
You have the right to ask for your health information to be sent to you in different ways. For example, you may ask that Partners not contact you with appointment reminders by telephone, or only call at your work or cell telephone number rather than home. When we request an address and telephone number(s) to contact you, it is your responsibility to give us telephone number(s) and an address that will allow us to carry out our needs to reach you and care for you. We may request the method and location where you wish to be contacted be in writing and that you contact us with any changes to this information. Partners must agree to any reasonable request and cannot ask you to explain the reason for your request. Partners can require you to give information as to how a payment will be handled, and what address a bill should be mailed to.
The Right to Look at and Get a Copy of Your Health Information.
You have the right to look at and get a copy of your health information that Partners keeps of your medical treatment and bills. You must ask for this in writing. We will respond within thirty (30) days from receipt of your request. If you ask for a copy of your records, you will be charged a fee.
If your request is denied, we will explain the reasons in writing and tell you which rights you have, if any, to a review of the denial. We may offer to give you a summary or explanation of the information you requested as long as you agree in advance to this and to any fees that it might cost. If you ask for information that we do not have, but we know where it is, we must tell you where to direct your request.
The Right to Change Your Health Information.
• You have
the right to ask us to change your health information related to your treatment
and bills if you think that there has been a mistake or
that information is missing.
• You must make your request
in writing and give the reason for why you want the change.
• We have 60 days to respond
to your request.
• If we have not been able
to act on the request within the 60 days, we will notify you that we are extending
the response time by 30 days.
• If we extend the response
time, we will explain the delay to you in writing and give you a new date
of when to expect a response.
• We may deny your request.
• If we deny your request,
we must give you a written statement with the reasons why, and what other
steps are available to you.
• If we grant the request,
we will ask you to tell us the persons you want to receive the changes. You
need to agree to have us notify them along with any others who received the
information before corrections were made and who may have
relied on the incorrect information to give you treatment.
The Right to Receive An Accounting of Disclosures (Record of When
Your Health Information was Shared without Your Written Permission (Authorization).
You have the right to get a record of the times that your health information has been shared. You must make your request in writing. You may request this as far back as six years, beginning April 14, 2003. The listing you get will include the date, name, and address (if known) of the person receiving your information. It will also include a brief description of the information given, a brief statement of why the information was shared.
The following exceptions apply.
• This does not include
sharing your medical information for the purpose of treatment, payment, or
health care operations.
• It also does not include:
• sharing your medical information
if your gave permission in writing (signed an authorization form)
• listing information in
facility directories
• sharing information with
persons involved in your care
• using your information
to communicate with you about your health condition
• sharing information for
national security or intelligence purposes or to correctional institutions
or law enforcement officials who have custody of you
• sharing information that
occurred before the date shown on this Notice.
• We have 60 days to respond
to your request. If we have not been able to act on the request within
the 60 days, we will notify you that we are extending the response time by
30 days.
• If we do that, we will
explain the delay to you in writing and give you a new date of when to expect
a response.
• Your first request for
a record in any 12-month period is free.
• We will charge a fee for
any other requests in that period.
• We will notify you of
the fee before we do the work. This will give you a chance to stop the request
if you do not wish to pay the fee.
The Right to Ask for a Paper Copy of this Notice.
You may ask for a paper copy of this Notice from the contact listed below. You can ask for a paper copy even if you agreed to receive the Notice by email.
C. OUR DUTIES WITH RESPECT TO YOUR HEALTH INFORMATION
Partners is required by law to keep your health information private. We are required to give people notice of our legal duties and privacy practices with respect to your health information.
Partners must abide by the terms of the Notice currently in effect. Partners reserves the right to change its privacy practices and the terms of this Notice at any time. Partners reserves the right to make the new Notice provisions effective for all protected health information that it maintains. If it does so, the updated Notice will be posted on the Partners web site and in all Partners registration areas for public viewing. You may request a copy of the current Notice at any time by calling any of the people listed at the end of this notice, or you may view it on our web site at www.partners.org.
D. HOW TO COMPLAIN IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN
VIOLATED
If you think that we may have violated your privacy rights or you disagree with any action we have taken with regard to your health information, we want you, your family, or your guardian to speak with us. If you present a complaint, your care will not be affected in any way. It is the goal of Partners HealthCare to give you the best care while respecting your privacy.
You may file a complaint by contacting a representative at any of the Partners sites that are listed at the bottom of this notice. You may also send a written complaint to U.S. Department of Health and Human Services, J.F.K. Federal Building – Room 1875, Boston, MA 02203, Voice phone 617-565-1340, or email to OCRComplaint@hhs.gov. We will take no retaliatory action against you if you file a complaint about our privacy practices.
E. PERSON TO CONTACT FOR INFORMATION OR WITH A COMPLAINT
If you have any questions about this Notice or any complaints, please contact a representative at any of the Partners sites that are listed at the bottom of this notice.
F. EFFECTIVE DATE OF THIS NOTICE
This Notice is effective as of April 14, 2003
PARTNERS HEALTHCARE MEMBER ORGANIZATIONS
This Notice applies to the following Partners organizations:
Partners HealthCare
Member Organizations |
Phone number
to contact when a patient wants to report a breach (complaint) |
| Partners HealthCare System, Inc. | |
| Partners Community HealthCare, Inc. | Compliance Line: (877) 670-8737 |
| Brigham and Women’s Hospital , Inc. Brigham Community Practices, Inc. Brigham and Women’s Physicians Organization, Inc. |
BWH Compliance Hotline: (617) 732-8907 BWH Patient Relations: (617) 732-6636 BWH Privacy/HIPAA Project Manager: (617) 732-6676 |
Faulkner Hospital, Inc.FRC, Inc. Faulkner Breast Centre, Inc. Faulkner Community Medical Corporation West Roxbury Medical Group, Inc. |
Privacy Officer/Director, Health Information Services: (617) 983-7458
|
Newton-Wellesley Hospital Newton-Wellesley Ambulatory Services, Inc. |
Compliance Help Line: 1 (800) 858-1752 |
The General Hospital Corporation (also known as, Massachusetts General Hospital) Massachusetts General Physicians Organization, Inc. |
Privacy Office/Health Info. Services:
Compliance Help Line: (617) 726-1446 |
| North End Community Health Committee, Inc. | Compliance Officer: (617) 742-9574 ext. 264 |
| The McLean Hospital Corporation | Privacy Office: (617) 855-3128 |
| The Spaulding Rehabilitation Hospital Corporation | (617) 573-2310 |
| Rehabilitation Hospital of the Cape and Islands Corporation | (508) 833-4050 |
| The Salem Hospital |
Compliance Help Line: (978) 825-6875 |
| Shaughnessy-Kaplan Rehabilitation Hospital, Inc. | Compliance Help Line: (978) 825-6875 Privacy Officer: (978) 745-9003 ext. 171 |
| Charter Professional Services Corporation | Compliance Help Line: (978) 825-6875 Assistant Privacy Officer: (978) 825-6422 |
| Union Hospital, Inc. | Compliance Help Line: (978) 825-6875 Privacy Officer: (781) 477-3281 |
| Partners Home Care, Inc.TLC Nursing, Inc. | (978) 236-1443 (781) 681-1270 |
|
Burlington Medical Group, P.C. Cape Ann Medical Center, Inc. Cape Ann Pediatricians, P.C. Charles River Medical Associates, P.C. Compass Medical, P.C. Hawthorn Medical Associates L.L.C.Lincoln Physicians, P.C. Pentucket Medical Associates, L.L.C.
|
Partners Community HealthCare, Inc. Compliance Line: (877) 670-8737 |
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