Notice of Privacy Practices
Effective Date: 9/1/15
“Rochester Regional Health” for the purpose of this notice, means itself and its affiliated licensed care providers.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS NOTICE ALSO DESCRIBES HOW SOME OR ALL OF MY PROTECTED HEALTH INFORMATION MAY BE CREATED AND/OR STORED IN A SHARED ELECTRONIC MEDICAL RECORD. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the Rochester Regional Health Call Center at 585.922.LINK (5465) or for long distance, use the toll free number 1-877-922-5465.
WHO WILL FOLLOW THIS NOTICE
This notice describes our practices and that of:
- All health care professionals authorized to enter information into your medical record maintained by or for a Rochester Regional Health affiliate.
- All departments and units of a Rochester Regional Health affiliate.
- Any member of a volunteer group we allow to help you while you are receiving services at a Rochester Regional Health affiliate.
- All employees, staff and other Rochester Regional Health personnel.
- All personnel, departments, sites, locations and affiliates of Rochester Regional Health (including Rochester Regional Health’s hospitals, off site locations including laboratory draw stations and medical offices, skilled nursing facilities, behavioral health programs, ambulatory and surgical care centers, urgent care clinics, rehabilitation centers, laboratories and physicians on Rochester Regional Health’s medical/dental staffs providing care and/or services at any Rochester Regional Health affiliate) follow the terms of this notice.
- Rochester Regional Health affiliates may share medical information with each other for treatment, payment or healthcare operations as described in this notice.
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 Rochester Regional Health. 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 Rochester Regional Health.
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.
We are required by law to:
- make sure that medical information that identifies you is kept private;
- provide you with this notice of our legal duties and privacy practices with respect to medical information about you; and
- follow the terms of the notice that is currently in effect.
For purposes of this notice, “medical information” means all individually identifiable information which is created or received by Rochester Regional Health and which relates to your past, present or future physical health or condition, the provision of health care to you or the past, present or future payment for health care provided to you. When used in this notice, “medical information” does not include mental health records, drug and alcohol treatment records, HIV related information or any other information protected by the New York Mental Hygiene Law, the New York Public Health Law or drug and alcohol abuse records protected by Part 2 of Title 42 of the Code of Federal Regulations.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we may use and disclose medical information without your authorization. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permit- ted to use and disclose information will fall within one of the categories.
- For Treatment. With certain exceptions, we may use and disclose your medical information to provide, coordinate or manage your health care and related services by the staff of the Rochester Regional Health affiliate and other health care providers, including consulting with other health care providers about your health care or referring you to another health care provider for treatment. For example, a doctor treating you in the hospital or Long Term Care affiliate for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments and care providers of the hospital or Long Terms Care affiliate also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
- For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive 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 healthcare operations. For example, we may use medical information to review our treatment and services, to evaluate the performance of our staff in caring for you and to educate Rochester Regional Health personnel. We may share your medical information with third party “business associates” that perform various activities (e.g., billing, transcription services) for Rochester Regional Health or its affiliates. Whenever an arrangement between Rochester Regional Health or its affiliates and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that will protect the privacy of your medical information.
- Appointment Reminders. We may use and disclose medical information to contact you to remind you that you have an appointment for treatment or medical care at Rochester Regional Health.
- Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible 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 demographic information about you to contact you in an effort to raise money for Rochester Regional Health and its operations through its foundations. We would release only demographic information to the applicable foundation, such as your name, address, phone number, age, gender, date of birth, health insurance status, department of service information, treating physician information, outcome information, and the dates you received services at Rochester Regional Health. If you do not want Rochester Regional Health’s foundations to contact you for fundraising efforts, you must notify the Rochester Regional Health Foundation administrative office at 585.922.4800. If you opt not to be contacted for fundraising purposes, we will make reasonable efforts to ensure that you are not contacted for fundraising purposes.
- Facility Directory. Unless you object or an emergency situation prevents us from asking you, we may include certain limited information about you in the facility directory while you are a patient/resident/participant at Rochester Regional Health. This information may include your name, location in the facility, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. The information contained in the facility directory 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.
- Individuals Involved in Your Care or Payment for Your Care. Unless you object, 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. 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, status and location.
- Research. We may use and disclose your medical information for research, regardless of the funding for research, provided that the Rochester Regional Health Clinical Investigation Committee waives the authorization requirement based upon a finding that the use or disclosure of your medical information involves no more that a minimal risk to your privacy. We may also use or disclose your medical information in a review in preparation for research, provided that the researcher represents to us that: (1) the use or disclosure is sought solely to review medical information as is necessary to prepare a research protocol or for similar purposes relating to the preparation for research; (2) no medical information is to be removed from our facility during the course of the review; and (3) the medical information sought is necessary for research purposes.
- 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 your health and safety or the health and safety of the public or another person.
Organ and Tissue Donation. 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.
Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs.
Public Health Risks. We may disclose medical information about you for public health activities related to prevention or control of disease, injury or disability. We may also disclose medical information about you to a public health authority (e.g., the Department of Health) that is permitted by law to collect or receive the information.
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.
Judicial and Administrative Proceedings. We may, upon certain conditions, disclose your medical information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, a subpoena, discovery request, or other lawful process.
Law Enforcement. We may release medical information in limited circumstances if asked to do so by a law enforcement official. Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner, medical examiner or funeral director as permitted by law to carry out their duties.
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 to assure the proper execution of a military mission. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence 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, other authorized persons or foreign heads of state or 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; (3) for the safety and security of the correctional institution; or (4) for law enforcement on the premises of the correctional institution.
HOW WE MAY USE AND DISCLOSE MENTAL HEALTH, CHEMICAL DEPENDENCY AND HIV-RELATED INFORMATION ABOUT YOU.
Uses and disclosures of mental health treatment records, drug and alcohol abuse records and/or HIV related information that may be made without a valid authorization are materially limited, and in some cases prohibited, by applicable New York law and/or federal regulations. In those instances, we will comply with the provisions of the more protective law or regulation because your privacy rights are expanded under those more stringent standards. The person or entity receiving any mental health, chemical drug and alcohol abuse or HIV-related information pursuant to any of these permitted uses or disclosure is required to maintain the confidentiality of the information received.
Mental Health and Drug and Alcohol Treatment Information.
Without your authorization, we may use and disclose your mental health and/or drug and alcohol treatment information under the following circumstances or to the following people or entities:
- Pursuant to an Order of a court requiring disclosure;
- To the Mental Hygiene Legal Service or to an attorney representing your interest in a proceeding in which involuntary hospitalization is at issue;
- To the Commission on Quality of Care for the mentally disabled;
- To the Medical Review Board of the State Commission of Correction;
- To an individual and a law enforcement agency when you present a serious and imminent danger to that individual;
- To the State Board for Professional Medical Conduct or the Office of Professional Discipline;
- With the consent of the Commissioner of Mental Health, to: (i) various governmental agencies; (ii) insurance companies requiring information necessary for payment; (iii) persons or agencies needing information to locate missing persons; (iv) governmental agencies in connection with criminal investigations; (v) qualified researchers; (vi) a coroner or a medical examiner; (vii) a District Attorney when such request is necessary to conduct a criminal investigation relating to patient abuse; or (viii) appropriate persons and entities when necessary to prevent imminent serious harm to you or another person;
- To a correctional facility at which you are an inmate;
- To a person otherwise qualified under New York Law;
- To a Director of Community Services; and
- To the State Division of Criminal Justice Services for the sole purpose of providing, facilitating, evaluating or auditing access by the Commissioner of Mental Health.
Without your authorization, we may use and disclose your HIV-related information to the following people or entities:
- To an agent or employee of a health facility or health care provider under certain circumstances, including when the information is necessary to care for you, your child or one of your contacts;
- To a federal, state, county or local health officer when such disclosure is mandated by federal or state law;
- To third-party payers and to insurance institutions, under certain circumstances, in order to receive payment for your care.
OTHER USES OF MEDICAL INFORMATION, MENTAL HEALTH RECORDS, DRUG AND ALCOHOL TREATMENT RECORDS AND HIV-RELATED INFORMATION NEEDING AN AUTHORIZATION.
Other uses and disclosures of medical information, mental health records, drug and alcohol treatment records and HIV- related information not covered by this notice or the laws that apply to us will be made only with your written authorization. For example, most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for market- ing purposes, including subsidized treatment communications, and disclosures that constitute a sale of protected health information require your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, 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 authorization, and that we are required to retain our records of the care that we provided to you.
SHARED ELECTRONIC MEDICAL RECORD.
Some or all of your medical information, including any of your mental health records, drug and alcohol treatment records and HIV- related information, may be created and/or stored in an electronic format. When permissible by law, only authorized healthcare providers and professionals providing care and services to you by or at Rochester Regional Health may access your medical information, including your mental health records, drug and alcohol treatment records and HIV- related information, electronically.
YOUR RIGHTS REGARDING MEDICAL INFORMATION, MENTAL HEALTH RECORDS, DRUG AND ALCOHOL TREATMENT RECORDS AND HIV-RELATED INFORMATION ABOUT YOU.
You have the following rights regarding medical information, mental health records, drug and alcohol treatment records and HIV-related information we maintain about you:
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and copy your medical information, mental health records, drug and alcohol treatment records and HIV-related information that may be used to make decisions about your care. Usually, this includes medical and billing records. If the requested medical information is maintained electronically and you request an electronic copy, we will provide access in an electronic format, if it is readily producible, or if not, in a readable electronic form and format mutually agreed upon.
To inspect and copy medical information, mental health records, drug and alcohol treatment records and HIV-related information, you must submit your request in writing to the Health Information Management Department at the Rochester Regional Health affiliate at which you received care. 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.
Your provider has the right to review the requested records before granting you access. In certain circumstances, the provider may deny all or part of your request for access. If you are denied access to medical information, you may request that the denial be reviewed. You may also appeal the denial. The Health Information Management Department at the Rochester Regional Health affiliate to which you made the request will provide you with the form necessary to appeal the denial.
Right to Amend. If you feel that your medical information, mental health records, drug and alcohol treatment records and HIV-related information 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 the Rochester Regional Health affiliate.
Your request for an amendment must be made in writing and submitted to the Health Information Management Department at the Rochester Regional Health affiliate which generated the record. 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, does not include a reason to support the request or 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 the Rochester Regional Health affiliate;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. We are not required to account for disclosures made: (1) to carry out treatment, payment or health care operations; (2) to you or your personal representative; (3) pursuant to an authorization given by you; (4) to other people involved in your care or made for notification purposes; (5) for national security or intelligence purposes; (6) to correctional institutions or law enforcement officials; or (7) prior to April 14, 2003. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations set forth in applicable statutes and regulations.
To request an accounting of disclosures, you must submit your request in writing to the Health Information Management Department at the Rochester Regional Health affiliate from which you wish to receive an accounting. Your request must state a time period for which you are asking for an accounting, which time period may not be longer than six years. Your request should indicate in what form you want the accounting (for example, on paper or electronically). The first accounting you request within any 12 month period will be free. We may charge you for the cost of providing additional accountings requested during the same 12 month period. We will notify you of the fee for each accounting in advance and allow you to modify or withdraw your request in order to reduce or avoid the fee.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information, mental health records, drug and alcohol treatment records and HIV-related 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 to your spouse.
When paying for a service or health care item out-of-pocket in full, you have the right to instruct your provider not to share your medical information, including your mental health records, drug and alcohol treatment records and HIV- related information, with your health plan.
We are not required to agree to your request. However, we must agree to your request to restrict disclosures of your medical information to a health plan if the disclosure is for the purposes of obtaining payment for your health care or other healthcare operations and is not otherwise required by law and we have been paid in full for the treatment we provided related to the medical information you have asked us not to disclose. 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 writing to the Health Information Management Department at the Rochester Regional Health affiliate which generated the record to be restricted. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, 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 Health Information Management Department at the Rochester Regional Health affiliate at which you are seeking care. We will not ask you the reason for your request. 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 obtain a paper copy of this notice at any time. You may obtain a copy of this notice at our website, www.rochesterregionalhealth.org or by calling the Rochester Regional Health Call Center at 585.922.LINK (5465) or by using our toll-free number1-877-922-5465. You may also request a paper copy of this notice at the admitting or registration department/area where you receive care.
We must notify you if we have reason to believe your medical information has been compromised due to unauthorized acquisition, access, use or disclosure, unless there is a low probability that the privacy or security of your medical information has been comprised.
CHANGES TO THIS NOTICE.
We reserve the right to change this notice and 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. The revised notice will be available upon request, in the admitting or registration department/area of each Rochester Regional Health affiliate and on our website.
COMPLAINTS REGARDING PRIVACY.
If you believe your privacy rights have been violated, you may file a complaint with Rochester Regional Health or with the Secretary of the Department of Health and Human Services. To file a complaint with Rochester Regional Health, call the Rochester Regional Health Call Center at 585-922-5465 or toll free 1-877-922-5465, or send your written complaint to:
Rochester Regional Health Call Center
Attention Privacy Officer
100 Kings Highway S.
Rochester, New York 14617
All complaints to the Secretary of the Department of Health and Human Services must be submitted in writing. You will not be penalized, denied care or retaliated against for filing a complaint.