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.

If you have any questions about this notice, please contact the Office of Quality and Patient Safety at 617-754-5164.

This notice describes the practices of:

• New England Baptist Hospital and all of its entities, sites, and locations. All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or hospital operations purposes described in this notice.
• Any health care professional authorized to enter information into your hospital chart on behalf of these entities.
• All departments and units of the hospital.
• Any member of a volunteer group we allow to help you while you are in the hospital.
• All employees, staff, and other hospital personnel.

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

We are required by law to:

• ensure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the notice that is currently in effect.

Understanding Your Health Record/Information. Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. This record typically contains your symptoms, medical history, examination, test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment
• means of communication among the many health professionals who contribute to your care
• legal document describing the care you received
• means by which you or a third-party payer can verify that services billed were actually provided
• tool in educating health professionals
• source of data for medical research
• source of information for public health officials charged with improving the health of the nation
• source of data for facility planning and marketing
• tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

• ensure its accuracy
• better understand who, what, when, where, and why others may access your health information
• make more informed decisions when authorizing disclosure to others

How we may store medical information about you. Your medical record may be handwritten, printed, typed, or in electronic digital media. Parts of the record that are handwritten, printed, or typed may also be converted to electronic digital media under Massachusetts law. We may destroy all or a portion of your medical record in the future, but only after the applicable legally required retention period has elapsed and we have notified the Massachusetts Department of Public Health in accordance with its regulations. At present, the Hospital’s record retention policy provides that medical records will be retained for a period of 20 years.

How we may use and disclose medical information. The following describes different ways that we are permitted to use and disclose medical information. For each category of uses or disclosures, we will explain what we mean, and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use your medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in caring for you at the hospital or outside the hospital. Different departments of the hospital also may share medical information about you in order to coordinate the different services/treatments you need, such as prescriptions, laboratory work, and x-rays. We may also disclose medical information about you to people who may be involved in maintaining your health or well-being during your hospital stay and after discharge, such as family members, friends, home health services, support agencies, clergy, or others who provide services that are necessary for your well-being.
• For Payment. We may use and disclose your medical information so that the treatment and services you receive at the hospital may be billed and payment may be collected from you, an insurance company, or a third party. We may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. We may also give information to someone who helps pay for your care.
• For Health Care Operations. We may use and disclose your medical information for hospital operations. Hospital operations are activities that are necessary to run the hospital and to make sure that all of our patients receive quality care. We may combine medical information about many hospital patients for purposes of making decisions about what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. When we do this, information that identifies you may be removed from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. If ownership of the hospital changes as a result of sale, transfer, merger or consolidation, your medical information would be disclosed to the new entity, if that entity was to follow the same privacy policies.

Other Examples of Health Care Operations

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

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

Activities. We may use your demographic information to contact you in an effort to raise money for the hospital and its operations. We would release only contact information, such as your name, address and phone number, and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you as part of its fundraising efforts, you must send a written notice to NEBH, Office of Philanthropy, 125 Parker Hill Avenue, Boston, MA 02120.

Hospital Directory. We may include certain limited information about you in the hospital directory while you are an inpatient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., good, fair, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your name may be given to a member of the clergy, even if they do not ask for you by name. If you do not want to be listed in the hospital directory please contact your nurse.

In disaster situations, those involving multiple casualties, we may release general information, such as: the hospital is treating four individuals received in transfer from another hospital.

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

As Required By Law. We will disclose your medical information when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose your medical information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be only to someone able to help prevent the threatened harm.

Special Situations. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Organ and Tissue Donation. If you are a potential organ donor, we may release medical information to organ procurement organizations or eye or tissue banks, as necessary, to facilitate organ or tissue donation and transplantation.

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

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

Organized Health Care Arrangements. New England Baptist Hospital and all of its entities, sites and locations participate in an Independent Practice Association/Physician Hospital Organization with certain affiliated entities, which is considered an Organized Health Care Arrangement (OHCA) under the Health Insurance Portability and Accountability Act (HIPAA).  A list of the OCHA’s affiliated members is available on the NEBH web site at www.nebh.org. Members of the OHCA share medical information to manage joint operational activities.

Public Health Risks. We may disclose your medical information for certain public health activities. These activities generally include the following:

• to prevent or control disease, injury, or disability;
• to report births and deaths;
• to report abuse and/or neglect of a child, elder, or disabled person;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Health Oversight Activities. We may, when requested, disclose your medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, certifications, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court order. Under certain circumstances, we may also disclose your medical information in response to a subpoena or other lawful process, but we will do so only if efforts have been made to tell you about the request or to obtain an order protecting the information requested or if you or a court have provided written authorization.

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

• In response to a court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the hospital; and
• In emergency circumstances: to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors or designees as necessary to carry out their duties.

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

Protective Services for the President and Others. We may disclose your medical information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations, if permitted by law.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official, under certain circumstances if permitted by law. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Situations in Which We are Required to Obtain your Authorization. For most situations not listed in this notice, we are required to obtain your authorization to release your health information. Some of these situations include:

• Most uses and disclosures of psychotherapy notes
• Uses and disclosures of your health information for marketing purposes (other than as part of treatment such as recommending our services)
• Disclosures that constitute a sale of your information (please note that we are required to include this point by law but we do not sell your information)

Other uses and disclosures not described in this Notice will be made only with your authorization.

Your Rights Regarding Medical Information About You.

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

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

To inspect and obtain a copy of your medical information that may be used to make decisions about you, you must submit your request in writing for hospital records to NEBH, Health Information Management, 125 Parker Hill Avenue, Boston, MA 02120. 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. For copies of your physician’s office records, please contact your physician’s office directly.

We may deny your request to inspect and obtain a copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you think that the medical 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 as long as the information is kept by or for the hospital. Your request for an amendment will become a legal part of your medical record, to be sent out along with the rest of the record whenever a request for copies is received. No part of the original documentation in the medical record can be destroyed.

To request an amendment of your hospital record, your request must be made in writing and submitted to NEBH, Health Information Management, 125 Parker Hill Avenue, Boston, MA 02120. To request an amendment of your physician office record, contact your physician’s office directly. 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 or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

• Was not created by us, or the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the hospital;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

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

To request this list or accounting of disclosures, you must submit your request in writing to NEBH, Health Information Management, 125 Parker Hill Avenue, Boston, MA 02120. Your request must state a time period, which may not be longer than six years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you. In addition, you have the right to restrict the disclosure to a health plan of a service for which you have personally paid in full.

To request restrictions on your hospital records, you must make your request in writing to: Office of Quality and Patient Safety, 125 Parker Hill Avenue, Boston, MA 02120. 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. To request restrictions on your physician office records, contact your physician’s office directly.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only at work or by mail.

To request confidential communications, you must make your request to NEBH Privacy Officer at 617-754-6575. We will not ask you the reason for your request. At our discretion, we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to be Notified of a Breach of Your Health Information. We take great care to protect the security of your health information. However, in the event of a breach, you have the right to be notified of the information that was breached and how you may protect yourself. We will notify you should a breach occur.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us at any time to give you a copy of this notice. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.nebh.org. To obtain a paper copy of this notice, please contact: NEBH, Patient Access Department, 125 Parker Hill Avenue, Boston, MA, 02120.

Changes to This Notice. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital. In addition, each time you register or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, a copy of the notice currently in effect will be available at your request.

Complaints. If you believe your privacy rights have been violated, you may file a complaint with the hospital. To file a complaint with the hospital, contact Office of Quality and Patient Safety, 125 Parker Hill Avenue, Boston, MA 02120. All complaints must be submitted in writing. You may also file a complaint with the Secretary of the Department of Health and Human Services, or the Office for Civil Rights.

• You will not be penalized for filing a complaint.

Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Effective Date 4/14/2016