Notice of Privacy Practices
How we may use and disclose your health information without
your written authorization
With Your Specific Written Authorization
Your Rights Regarding Your Health Information
How to Obtain a Copy of This Notice and Revised Notices
How to File a Complaint
Acknowledgment of Receipt of Notice of Privacy Practices
Authorization to disclose protected health information (HIPPA)
Notice of Privacy Practices, Effective Date: April 14, 2003
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.
Tufts Medical Center/the Floating Hospital provides health care to patients jointly with physicians and other health care professionals. This notice applies to Tufts Medical Center and the physician groups listed at the end of this notice.
We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice which describes the health information privacy practices of our hospital and affiliated health care providers that jointly provide health care services with our hospital. This notice will tell you about the ways in which we may use and disclose health information about you or your child. We also describe your rights and our duties regarding the use and disclosure of health information.
A copy of our current notice will always be posted in prominent locations, including admitting and registration areas. You will also be able to obtain a copy by accessing the Tufts Medical Center website at www.tuftsmedicalcenter.org or calling us at 617-636-4422 or asking for one at the time of your next visit.
If you have any questions about this notice or would like further information, please contact the Tufts Medical Center Privacy Officer at 617-636-4422.
How we may use and disclose your health information without your written authorization
1. Treatment, Payment and Business Operations
We may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations. In some cases, we may also disclose your health information for payment activities and certain business operations of another health care provider or payor. Below are further examples of how your information may be used and disclosed for these purposes.
Treatment
We may use and disclose health information about you to provide medical treatment and services. For example, we may disclose health information about you to doctors, nurses, technicians, residents, students, or other hospitals or home health agencies so that they can provide care to you or so that they can coordinate your continuing care.
Payment
We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company in order to obtain reimbursement after we have treated you, or to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition in order to obtain pre-approval for your treatment, such as admitting you to the hospital for a particular type of surgery. Finally, we may share your information with other health care providers and payors for their payment activities.
Business Operations
We may use your health information or share it with others in order to conduct our business operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you. Finally, we may share your health information with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
Appointment Reminders, Treatment Alternatives, Benefits and Services
In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services at our facility. We may also use your health information in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.
Fundraising
To support our business operations, we may use demographic information about you, including information about your age and gender, where you live or work, and the dates that you received treatment, in order to contact you to raise money to help us operate. We may also share this information with a charitable foundation that will contact you to raise money on our behalf.
Business Associates
We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. If we do disclose your health information to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your health information.
2. Patient Directory/Family and Friends
If you do not object, we will include your name, your location in our facility, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation in our Patient Directory while you are a patient in the hospital. This directory information, except for your religious affiliation, may 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 he or she doesn’t ask for you by name.
If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative or another person responsible for your care about your location and general condition here at the hospital, or about the unfortunate event of your death. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.
3. Public Need
We may use your health information, and share it with others, in order to comply with the law or to meet important public needs that are described below:
Public Health Activities - We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling or monitoring disease, injury or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so.
- Victims of Abuse, Neglect or Domestic Violence
We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect or domestic violence.
- Health Oversight Activities
We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facility. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.
- Product Monitoring, Repair And Recall
We may disclose your health information to a person or company that is regulated by the Food and Drug Administration for the purposes of reporting or tracking product defects or problems, repairing, replacing, or recalling defective or dangerous products, and monitoring the performance of a product after it has been approved for use by the general public.
We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute. We may disclose your information in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure.
We may disclose your health information to law enforcement officials for the following reasons:
- To comply with court orders or laws that we are required to follow;
- To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
- If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
- If we suspect that your death resulted from criminal conduct;
- If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).
- To Avert a Serious and Imminent Threat to Health or Safety
- National Security and Intelligence Activities or Protective Services
- Military And Veterans
If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission.
- Inmates And Correctional Institutions
If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined.
- Workers’ Compensation
- Coroners, Medical Examiners and Funeral Directors
- Organ and Tissue Donation
In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.
- Research
In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under certain circumstances, we may use and disclose your health information without your written authorization, including if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy, or for purposes of preparing a future research project.
4. Completely De-identified or Partially De-identified Information
We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is "completely de-identified." We may also use and disclose "partially de-identified" health information about you for public health and research purposes, or for business operations, if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number).
5. Incidental Disclosures.
While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.
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With Your Specific Written Authorization
Other uses and disclosures of your health information not covered by this Notice or the laws that apply to us will only be made with your written permission or authorization. You may also initiate the transfer of your records to another person by completing a written authorization form. If you provide us with written authorization, you may revoke that written authorization at any time, except to the extent that we have already relied upon it. To revoke a written authorization, please write to Correspondence Supervisor, Tufts Medical Center Medical Records Department, 800 Washington St, Boston, MA 02111. 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 provide to you.
Certain health information. In most cases, we will not be able to disclose the following types of health information without your written
authorization or a court order:
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Your Rights Regarding Your Health Information
You have the following rights regarding health information we maintain about you:
1. Right To Inspect and Copy Records.
You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. To inspect or obtain a copy of your health information, please submit your request in writing to the Correspondence Section, Tufts Medical Center Medical Records Department, 800 Washington St., Boston, MA 0211. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request.
We will ordinarily respond to your request within 30 days if the information is located in our facility and within 60 days if it is located off-site at another facility. If we need additional time to respond, we will notify you within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we deny part or all of your request, we will provide a written denial notice that explains our reasons for doing so, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the United States Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.
2. Right to Amend Records
If you believe that the health 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 in our records. To request an amendment, please write to the Tufts Medical Center Privacy Officer, 800 Washington St., Boston, MA 02111. Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.
If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement which we will include in your records. We will also include information on how to file a complaint with us or with the United States Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.
3. Right to an Accounting of Disclosures.
You have a right to request an "accounting of disclosures" which identifies certain other persons or organizations to whom we have disclosed your health information in accordance with applicable law and the protections afforded in this Notice of Privacy Practices. An accounting of disclosures does not describe the ways that your health information has been shared within and between the hospital and the physician groups listed at the end of this notice, as long as all other protections described in this Notice of Privacy Practices have been followed.
An accounting of disclosures also does not include information about disclosures made: to you or your personal representative; pursuant to your written authorization; for treatment, payment or business operations; from the patient directory; to family and friends involved in your care or payment for your care; incidental to permissible uses and disclosures of your health information; for purposes of research, public health or our business operations of partially de-identified health information that does not directly identify you; to federal officials for national security and intelligence activities; with respect to inmates, to correctional institutions or law enforcement officers; before April 14, 2003.
To request an accounting of disclosures, please write to the Correspondence Section, Tufts Medical Center Medical Records Department, 800 Washington St., Boston, MA 02111. Your request must state a time period within the past six years (but after April 14, 2003) for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2004 and January 1, 2005. You have a right to receive one accounting within every 12 month period for free. However, we may charge you for the cost of providing any additional accounting in that same 12 month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.
Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.
4. Right to Request Additional Privacy Protections
You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our business operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. To request restrictions, please write to the Tufts Medical Center Privacy Officer at 800 Washington St., Tufts Medical Center # 4422, Boston, MA 02111. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.
We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.
5. Right to Request Confidential Communications
You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. To request more confidential communications, please write to the Tufts Medical Center Privacy Officer at 800 Washington St., Boston, MA 02111.
We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location.
How Someone May Act On Your Behalf.
You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.
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How to Obtain a Copy of This Notice and Revised Notices
You have the right to a paper copy of this notice. You may request a paper copy at any time, even if you have previously agreed to receive this notice electronically. To do so, please call the Tufts Medical Center Privacy Officer at 617-636-4422. You may also obtain a copy of this notice from the Tufts Medical Center website at www.tuftsmedicalcenter.org or by requesting a copy at your next visit. We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. The revised notice will apply to all of your health information. We will post any revised notice in prominent locations in the hospital. You will also be able to obtain your own copy of the revised notice by accessing the Tufts Medical Center website at www.tuftsmedicalcenter.org, calling our office at 617-636-4422 or asking for one at the time of your next visit. The effective date of the notice will always be noted in the top right corner of the first page. We are required to abide by the terms of the notice that is currently in effect.
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How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the Tufts Medical Center Privacy Officer at 617-636-4422. No one will retaliate or take action against you for filing a complaint.
This Notice of Privacy Practices applies to Tufts Medical Center and the following physician groups providing services at Tufts Medical Center:
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Tufts Medical Center Emergency Associates, P.C. |
Pratt Otolaryngology – Head & Neck Surgery Associates, Inc. |
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New England Medical Center Group Practice, Inc. (d/b/a Pratt Neurosurgery Associates) |
Pratt Pathology Associates, Inc. |
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Pediatric Gastroenterology Associates at Floating Hospital, P.C. |
Pratt Pediatric Associates, Inc. |
|
Pratt Anesthesiology Associates, Inc. |
Pratt Psychiatric Associates, Inc. |
|
Pratt Medical Group, Inc. |
Pratt Radiation Oncology Associates, Inc. |
|
Pratt Medical & Surgical Dermatology Associates, Inc. |
Pratt Radiology Associates, Inc. |
|
Pratt Neurology Associates, Inc. |
Pratt Rehabilitation Medicine Associates, Inc. |
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Pratt OB/GYN Associates, Inc. |
Pratt Surgical Associates, Inc. |
|
Pratt Ophthalmology Associates, Inc. |
Pratt Urology Associates, Inc. |
Certain inquiries or requests directed to the Tufts Medical Center Privacy Officer or Medical Records Department under this Notice may be forwarded to the Privacy Officer of one of the above-listed physician groups for a response, as appropriate, or you may be directed to contact that person directly.
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Acknowledgment of Receipt of Notice of Privacy Practices
By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by Tufts Medical Center and the physician groups listed in this Notice, and how I may obtain access to and control this information.
_________________________________________
Signature of Patient or Personal Representative
_________________________________________
Print Name of Patient or Personal Representative
_________________________________________
Date
_________________________________________
Description of Personal Representative’s Authority
Documentation of Good Faith Effort
Requested that patient/patient’s personal representative acknowledge receipt of Notice of Privacy Practices, but patient/patient’s personal representative refused to acknowledge receipt of Notice of Privacy Practices.
The Notice of Privacy Practices was mailed to the patient/patient’s personal representative at the address of record.
Other: _________________________________________________________________________
____________________________________________ ____________________________
Witness Date
Authorization to disclose protected health information (HIPPA)
The Notice of Privacy Practices is also available in other languages. Contact Interpreter Services at (617) 636-5547 or the Admitting Office at (617) 636-6000.
Dear Patient:
Please complete this form and return it to the address below in order for Tufts Medical Center to use or disclose your protected health information as described below.
Patient Information:
Medical Record # ___________________
Name: ______________________________________ Date of Birth: _______________
Address:_______________________________________________________________
Area Code/Telephone #:_____________________ Alternate #:____________________
Purpose of the Requested Use or Disclosure:
Medical Treatment or Transfer: ______ Legal: ______ Insurance: ______
Personal: _____ Other (please specify): _____________________________________________
Specific Description of Information (must include date(s):
Date(s) of Treatment: _________________________________
____ ER Record
____ Discharge Summary _______ Pathology Reports
____ Operative Report _______ Lab Reports
____ Clinic Visit Note _______ X-Ray/MRI/Cat Scan Reports
____ Complete Record _______ Therapy (Physical/Occupational)
____ Abstract of Record: (e.g. History & Physical, Operative & Discharge Reports, Consults,
Lab Reports, ER Reports – specify elements to be released) _____________________
____Other: (please specify) __________________________________________________
Release of Specifically Protected Health Information
If the information described above includes information in any category below, I specifically authorize the use or disclosure of such information. Please indicate the specific information to be used or disclosed and sign where indicated:
____ HIV/AIDS testing/test results (patient authorization required for each release request) Specify date: __________________
_________________________________________ _______________
Signature of Patient/Legal Representative Date
Relationship to Patient or Authority to Act on Patients’ behalf: _____________________
*************************************************************************
____ Genetic testing/test results Specify date and type of test: ___________________
_________________________________________ _______________
Signature of Patient/Legal Representative Date
Relationship to Patient or Authority to Act on Patients’ behalf: _____________________
Information identified in any category below:
____ Alcohol and drug abuse records Specify dates: ____________________
____ Mental health treatment/psychotherapy
____ Sexual assault counseling
____ Social service counseling/therapy
____ Venereal diseases/sexually-transmitted diseases ______________________________
Signature of Patient/Legal Representative Date
Relationship to Patient or Authority to Act on Patients’ behalf: _____________________
To Whom Information Will Be Disclosed. I authorize Tufts Medical Center to disclose copies of my protected health information described above to: (complete name and mailing address)
Name: ______________________________________________________
Street Address: ______________________________City______________
State _____ Zip Code____ Attention: ______________________________
Expiration. This authorization will expire automatically in 6 months or on the following date or event that relates to me or the purpose of the use or disclosure: __________________
Specific Understandings
I understand that I may revoke this authorization by notifying the Medical Records Department at any time in writing, but if I do it won’t have any affect on actions taken by Tufts Medical Center before they received the revocation. I may refuse to sign this authorization. My health care, the payment for my health care, and my health care benefits will not be affected if I do not sign this form (except if health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party). I have a right to receive a copy of this form after I have signed it.
By signing this authorization form, I authorize the use or disclosure of my protected health information as described above. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above.
_________________________________________ ______________
Signature of Patient/Legal Representative Date
Relationship to Patient or Authority to Act on Patient’s Behalf: _____________________
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