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  How
We may Use and Disclose Your Health Information
Your
Rights Concerning Your Health Records
For
More Information or to Make a Complaint
University Hospital is committed to maintaining an
institutional culture and working environment that promote
corporate integrity and ethical behavior. The Office
of Hospital Compliance is responsible for monitoring
the activities of the hospital and for promoting policies
and procedures that ensure privacy and respect for our
patients.
Please read the following notice on the hospital’s
practices related to patient privacy. For additional
information or to register a concern, please contact:
Dara Quinn, MHA, RHIA
Senior Compliance Officer
(973) 972-3450 (Office)
(973) 972-8942 (Direct)
quinnds@umdnj.edu
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.
We, at UMDNJ, understand that health information about
you and your health is personal.
We therefore are committed to and required by law to
maintain the privacy of your health information and
to provide you with notice of legal duties and privacy
practices with respect to your health information. We
will not use or disclose your health information except
as described in this Notice. This Notice applies to
all of the health information maintained by our units,
and our Centers and Institutes, which are collectively
referred to as UMDNJ.
UMDNJ Units
Graduate School of Biomedical Sciences
New Jersey Dental School
New Jersey Medical School
NJ Med P.C.
Robert Wood Johnson Medical School
Robert Wood Johnson University Medical Group School
of Health Related Professions
School of Nursing
School of Osteopathic Medicine
School of Public Health
University Hospital
For a complete listing of the Centers and Institutes
of UMDNJ, please go to our web site:
http://www.umdnj.edu/complweb/center-inst.htm
The units, centers, and institutes of UMDNJ may share
your health care information with each other, as necessary
to carry out treatment, payment, or health care operations.
How
We May Use and Disclose Your Health Information
We may use and disclose your health information as
described below. However, this is only meant to give
you a general overview and not to describe all specific
possible uses and disclosures that may occur.
Treatment
We may use your health information to provide medical/dental
treatment, items or services. For example, we may disclose
all or any portion of your health information to your
attending physician, treating physician, treating dentist,
consulting physician(s), nurses, technicians, medical
students, dental students, and other health care professionals
who have a need for such information for your care and
treatment.
Also, different departments may share health information
about you in order to coordinate specific services,
such as prescriptions, lab work and x-rays. We may also
disclose your health information to people outside UMDNJ
who may be involved in your medical/dental care, such
as family members, social service, clergy and others
that provide services that are part of your care. Also,
our staff may discuss your care in a case conference.
Treatment Alternatives
We may use and disclose your health information to
tell you about possible treatment options or alternatives
or other health related benefits that may be of interest
to you.
Payment
We may use and disclose health information about you
so that we may bill and receive payment for treatment
and services that you receive. Your information may
also be necessary for purposes of determining coverage,
medical necessity, pre-authorization or certification
and for utilization management. The information may
be released to an insurance company, third party payer
or other entity (or their authorized representatives)
involved in the payment of your medical bill and may
include copies or portions of your medical/dental record,
which are necessary for payment of your account. For
example, a bill sent to an insurance company may include
information that identifies you, your diagnosis, and
the procedures and supplies used. Also, your health
information may be disclosed to consumer reporting and/or
to collection agencies.
Healthcare Operations
We may use and disclose your health information for
our health care operations, including quality assurance,
utilization review, medical/dental review, internal
auditing, accreditation, social services certification,
licensing or credentialing activities of UMDNJ, certain
medical/dental research, and educational purposes. For
example, UMDNJ may review your health information to
make sure that UMDNJ is providing quality care to all
of its patients.
Other Health Care Providers,
Health Plans, and Clearinghouses
We may use and disclose your health information to
your treating provider or healthplan, or a clearinghouse
involved in the billing of services and treatment provided
to you, for the purpose of providing you treatment,
receiving or processing payment, and to conduct certain
operational activities as permitted by law.
Activities of Organized
Health Care Arrangements in Which We Participate
For certain activities, the various components of UMDNJ
(listed earlier in this Notice) and other independent
providers are called an Organized Health Care Arrangement.
We may disclose information about you to health care
providers participating in our Organized Health Care
Arrangements as necessary to carry out our treatment,
payment, or health care operations. All participants
in our Organized Health Care Arrangements have agreed
to abide by the terms of this Notice with respect to
your health care information created or received as
part of the delivery of health care services to you
at UMDNJ.
Appointment Reminders
We may use and disclose your health information to
contact you as a reminder that you have an appointment
for treatment or medical care or dental care at UMDNJ.
Facility Directory
This section only pertains to the units at UMDNJ that
utilize facility directories.
Unless you object, we may include certain limited information
about you in the facility directory while you are a
patient at our facilities. This information may include
your name, location in UMDNJ, your general condition
(e.g., fair, stable, etc.) and your religious affiliation.
This is so your family and friends can visit you in
the UMDNJ facility and generally know how you are doing.
The directory information, except for your religious
affiliation, may only be given 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 don’t ask for you by name. If you
do not want to be included in the facility directory
or to limit those who can know that you are in the facility,
inform the admitting staff.
Persons Involved in Your
Care
Unless you object, we may disclose your health information
to family members, other relatives, close personal friends,
or any other person(s) who are involved with your medical
care, dental care, or payment.
Disaster Relief
Unless you object, we may use or disclose your health
information to a public or private entity authorized
by law or by charter to assist in disaster relief efforts
including notifying your family about your condition,
status and location.
Health Related Benefits
and Services
We may use and disclose your health information to
tell you of health-related benefits or services that
may be of interest to you.
Business Associates
We may use and disclose health information to business
associates. A business associate is an individual or
entity under contract with us to perform or assist UMDNJ
in a function or activity which requires the use or
disclosure of health information.
Examples of business associates, include, but are not
limited to, copy services used by us to copy medical/dental
records, consultants, accountants, lawyers, and medical
transcriptionists. We require the business associate
to enter into an agreement to protect the confidentiality
of your health information.
Research
While most uses and disclosures related to research
require your authorization, in some limited situations
we may disclose your health information to researchers
when their research has been approved by an Institutional
Review Board or a similar privacy board that has waived
the individual authorization requirement in accordance
with the regulations covering this area.
De-Identified Data or
Limited Data Sets
We may use or disclose health information about you
if we remove all information that could be used to identify
you, i.e. “de-identified” information. We
are required to remove over fifteen (15) different pieces
of information that could be used to possibly identify
you. We may also use or disclose a limited amount of
health information about you in a “limited data
set” for the purposes of research, public health,
or health care operations if we enter into a data use
agreement with the recipient of the data.
Organ Procurement Organizations
We may use and disclose your health information to
organ procurement organizations and other entities engaged
in the procurement, banking or transplantation of organs
for the purpose of tissue donation and transplant.
Fundraising
We may use and disclose certain health information
to contact you in an effort to raise money for UMDNJ
and or its units. We may disclose certain health information
to a foundation related to UMDNJ so that the Foundation
may contact you in its effort to raise money. The information
released would only be contact information, such as
your name, address, phone number, and the dates you
received treatment or services at UMDNJ. If you do not
want UMDNJ to contact you for fundraising efforts, you
must notify the Foundation of UMDNJ, 1 World’s
Fair Drive, Suite 2100, Somerset, NJ 08873 in writing.
Health Oversight Agencies
We may use and disclose your health information to
a health oversight agency for activities authorized
by law, including, but not limited to, licensure, certification,
audits, investigations and inspections. These activities
are necessary for the government and certain private
health oversight agencies to monitor the healthcare
system, government programs, and compliance with civil
rights.
Law Enforcement
We may use and disclose your health information for
law enforcement purposes to a law enforcement official
if required by law, or where permitted by law, or in
response to a valid subpoena. Also, we may disclose
health information if it is necessary for law enforcement
authorities to identify or locate an individual.
Disclosures in Judicial/Legal
Proceedings
We may use and disclose your health information to
a court or administrative agency when a judge or administrative
agency orders us to do so. We may also use and disclose
information about you in legal proceedings, such as
in a response to a discovery request, subpoena, court
order, etc. Also, UMDNJ may use or disclose your health
information in preparation for any dispute or litigation
between you and UMDNJ.
Public Health Risk
We may use and disclose your health information to
public health or legal authorities charged with preventing
or controlling disease, injury or disability. For example,
we are required by law to report the existence of a
communicable disease, such as acquired immune deficiency
syndrome (“AIDS”), to the New Jersey State
Department of Health to protect the health and well
being of the general public. Other activities generally
disclosed include the following:
- To prevent or control disease, injury or disability.
- To report births and deaths.
- To report child abuse and neglect.
- To report reactions to medications or problems
with products.
- To notify a person who may have been exposed to
a communicable disease or may be at risk for contracting
or spreading a disease or condition.
- To notify the appropriate government authority
if UMDNJ believes a patient has been the victim of
abuse, neglect or domestic violence.
Safety of a Person or
the Public
We may use and disclose your health information to
prevent or lessen a serious and imminent threat to the
health or safety of a person or the public.
Workers’ Compensation
We may use and disclose health information about you
for workers’ compensation or similar programs.
These programs provide benefits for work-related injuries
or illnesses.
Military/Veterans
We may use and disclose your health information as
required by military command authorities, if you are
a member of the armed forces.
Inmates
If you are an inmate of a correctional institution
or under the custody of a law enforcement officer, we
may release your medical/dental record information to
the correctional institution or law enforcement official.
This release would be necessary:
- for the institution to provide you with health
care;
- to protect your health and safety and that of others;
- for the safety and security of the correctional
institution.
Required by Law
We may use and disclose health information about you
when required to do so by State or Federal law. For
example, we may disclose certain health information
to those persons who have a risk exposure related to
a communicable disease, as required by New Jersey law.
National Security and
Intelligence Activities
We may use and disclose your medical/dental information
about you to authorized federal officials for intelligence,
counterintelligence, and other National Security activities
as authorized by law. We may also disclose health information
about you to authorized federal officials so they may
provide protection to the President or other authorized
persons.
Coroners, Medical Examiners,
Funeral Directors
We may release your health information to a coroner
or medical examiner. This may be necessary, for example,
to identify a deceased person or to determine a cause
of death. UMDNJ may also release your health information
to funeral directors as necessary to carry out their
duties.
Employers
We may use and disclose your health information to
your employer to conduct medical surveillance of the
workplace, or to evaluate whether you have a work-related
illness or injury.
Secretary of the Department
of Health and Human Services
We may use and disclose your health information when
required by the Secretary of Health and the Department
of Health and Human Services for purposes of investigating
or determining compliance with the privacy law.
Other Uses
Any other uses and disclosures of your health information
will be made only with your written authorization.
Your
Rights Regarding Your Health Records
Although your health records are UMDNJ’s property,
you have the following rights:
- Right to Confidential
Communications
You have the right to receive confidential communications
of your health information by alternative means or
at alternative locations. To exercise your right,
please write to the address at the end of this section.
- Right to Request
to Inspect and to Obtain a Copy
You have the right to inspect and to obtain a copy
of your health information. However, such requests
may be denied as permitted under the law. You have
the right to appeal such denials. To exercise your
right, please write to the address at the end of this
section. (Copying fees may be imposed.)
- Right to Request
Amendment
You have the right to request to amend your health
information. However, UMDNJ may deny your request
to amend your health information under certain circumstances.
All requests for amendments must be in writing and
provide a reason supporting your request for an amendment.
To exercise your right, please write to the address
at the end of this section.
- Right to Request
Restrictions
You have the right to request restrictions on certain
uses and disclosures of your health information. However,
UMDNJ is not required to agree to such request. You
have the right to receive confidential communications
of your health information by alternative means or
at alternative locations. You must communicate your
specific request in writing by using the proper form.
To exercise your right, please write to the address
at the end of this section.
- Right to an Accounting
of Uses and Disclosures
You have the right to request that we provide you
with an accounting of disclosures we have made of
your health information. An accounting is a list of
disclosures. This list will not include disclosures
of your health information made for treatment, payment,
or health care operations, made to you, or made pursuant
to an authorization signed by you.
The request should state the time period for which
you wish to receive an accounting. This time period
should not be longer than six (6) years and should
not include dates before April 14, 2003.
The first accounting you request within a twelve (12)
month period will be free. For additional requests
during the same twelve month period, we will charge
you for costs of the accounting. We will notify you
of the amount we will charge and you may choose to
withdraw or change your request before you are charged
any costs.
To exercise your right, please contact the address
below.
- Right to Receive
A Copy of this Notice
You have the right to receive a paper copy of this
Notice, upon request. You may also obtain a copy of
this notice at our website, www.umdnj.edu/complweb.
- Right to Revoke Your
Prior Authorization
You have the right to revoke your authorization (your
permission) to use or disclose your health information
except to the extent that action has already been
taken in reliance on your prior authorization. To
exercise your right, please contact the address below.
All requests to exercise your rights above must be
made in writing to the address below:
Director of Medical Records
Medical Record Department
University Hospital
150 Bergen Street
Room B-439
Newark, New Jersey 07103-2406
Or
University Hospital’s
Privacy Officer at
(973) 972-6274
For
More Information or to Make a Complaint
If you have questions and would like additional information,
you may call the HIPAA hotline at (800) 215-9664 or
contact University Hospital’s Privacy Officer
at (973) 972-6274.
If you believe your privacy rights have been violated,
you may file a complaint with UMDNJ or with the Secretary
of the Department of Health and Human Services.
To file a complaint, please contact University Hospital’s
Privacy Officer at (973) 972-6274 and University Hospital’s
Patient Advocate located in the lobby of the hospital
in Room C242.
There will be no retaliation for filing a complaint.
Changes to This Notice
UMDNJ will abide by the terms of the Notice currently
in effect. However, UMDNJ reserves the right to change
the terms of its Notice and to make the new Notice provision(s)
effective for all health information that it maintains.
UMDNJ will promptly post the revised Notice on the UMDNJ
web site: www.umdnj.edu/complweb.
Reliance on this Notice
by Other Healthcare Entities
UMDNJ may sometimes participate in an organized healthcare
arrangement with providers and entities that may not
be employed by UMDNJ, but participate in your health
care. Any providers or entities participating in this
arrangement may rely on this Notice as providing you
with notice of their privacy practice.
Effective Date
The effective date of the Notice is April 14, 2003
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