Effective as of: February 7, 2019
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 Privacy Officer, Valley Health System by calling 201-291-6329.
I. WHO THIS NOTICE APPLIES TO.
This Notice describes the health information and related practices of Valley Health System, which includes:
- All subsidiaries and affiliates of Valley Health System, and departments thereof, including The Valley Hospital, Inc.; Valley Home Care, Inc.; Valley Physician Services NY, PC; and Valley Physician Services, PC (t/a Valley Medical Group). These separate legal entities comprise and are collectively referred to in this Notice as "Valley Health System", "We" or "Our". These separate legal entities may use and disclose certain information about you between each other as permitted in this Notice.
- Any member of a volunteer group we allow to help you while you are at a Valley Health facility or practice.
- All employees, staff and other Valley Health System workforce.
- Employees, staff, volunteers and other workforce of the Valley Hospital Foundation, Inc., but only related to fundraising activities of Valley Health System as described in this Notice.
- Any healthcare professional authorized to enter information into your medical record, such as third party healthcare professionals who are on the Medical Staff at The Valley Hospital or provide medical services to or at Valley Health System. Valley Health System participates as an "organized healthcare arrangement" (an "OHCA") with these third party healthcare professionals and may exchange with or receive your information from such entities for treatment, payment, healthcare operations and other purposes permitted or required by law as related to the OHCA and as described in this Notice.
II. OUR PLEDGE REGARDING YOUR INFORMATION.
We understand that information about you and your health is personal. We are committed to protecting such information about you. We create a record of the care and services you receive at Valley Health System. We need this record to provide you with quality care and to comply with certain legal requirements.
This Notice applies to all your individually identifiable health information collected, created or received by Valley Health System, and relates to your past, present or future physical or mental health or condition, or Valley Health System providing healthcare to you in the past, present or in the future. This is referred to as your "protected health information". Your protected health information may be found in our records of your care generated by Valley Health System facilities, agencies and practices, their healthcare professionals and other healthcare professionals. Other healthcare professionals, such as your personal doctor, may have different policies or notices regarding the doctor's use and disclosure of your protected health information created in the doctor's office or clinic.
This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of such information.
We are required by law to:
- make sure that protected health information that identifies you is kept private;
- give you this Notice of our legal duties and privacy practices concerning such information about you; and
- follow the terms of the Notice that is currently in effect.
III. HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU.
We use and disclose protected health information in many ways. For each category of uses or disclosures described in this Notice, we will explain what we mean and give some examples. It is not possible to describe each and every use or disclosure that may occur in a particular category listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. If a use or disclosure does not fall into one of these categories, we will generally be required to obtain your written authorization prior to disclosure.
- For Treatment. We may use protected health information about you to provide you with medical treatment or services. We may disclose such information about you to doctors, nurses, technicians, nursing and medical students or other Valley Health System personnel who are involved in taking care of you, for example, while admitted at The Valley Hospital, Valley Home Care or after discharge. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments and facilities of Valley Health System also may share protected health information about you in order to coordinate the different care you need, such as prescriptions, referrals, lab work and X-rays. We also may disclose such information about you to people who may be involved in your healthcare such as rehabilitation centers, your primary care provider or other individuals providing services that are part of your care.
- For Payment. We may use and disclose protected health 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 another responsible third party. For example, we may need to give your health plan information about surgery you received at The Valley Hospital or care received through Valley Home Care so that your health plan will pay us or reimburse you for the services provided. We may also tell your health plan about a treatment you are going to receive from Valley Medical Group to obtain prior approval or to determine whether your plan will cover the treatment. We may also disclose your information for these purposes to individuals or entities that provide us with billing or collection services.
- For Healthcare Operations. We may use and disclose protected health information about you for Valley Health System healthcare operations. These uses and disclosures are necessary to run Valley Health System, and to provide all of our patients with quality care. For example, we may use your information to review our treatment and services and to evaluate the performance of our staff or other healthcare professionals in caring for you. We may also combine information about Valley Health System patients to decide what additional services are needed, what services are not needed or whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, nursing and medical students and other individuals for review and learning purposes. We may also, subject to certain requirements, combine patient information we have with patient information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.
- Health Information Exchange: We may partner with one or more Health Information Exchange Organizations ("HIEs"), such as Jersey Health Connect, CommonWell Health Alliance or the state-owned and operated New Jersey Health Information Network ("NJHIN") to access and disclose (share) your information electronically for the purposes described in this Notice, including treatment, payment or healthcare operations. These HIEs are governed by rules designed to protect patient confidentiality, privacy and security. The purpose of an HIE is to allow participating physicians, healthcare facilities or other authorized entities to share your information electronically, which can help to reduce medical errors, eliminate redundant care and reduce unnecessary costs. An HIE may also allow you to access your information exchanged through the HIE. You have a right to choose not to participate in any such HIE. Please visit our website at www.ValleyHealth.com for additional information about the HIEs that we participate in and about how you can exercise your right to not participate in one or more of these HIEs. If you choose to not participate in any one or more HIE, your health information will not be available for access through such HIE; however, it may remain available for access through other mechanisms if permitted or required by applicable law.
- Appointment Reminders. We may use and disclose your protected health information to contact you as a reminder that you have an appointment for treatment or medical care.
- Treatment Alternatives. We may use and disclose your protected health 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 your protected health information to tell you about health-related benefits or services we provide that may be of interest to you.
- Fundraising Activities. We may use demographic information about you, such as name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of services, department of services, treating physician or information regarding outcome, to contact you in an effort to raise money for Valley Health System. We may disclose certain information to The Valley Hospital Foundation so that the Foundation may also contact you regarding these fundraising efforts. You are free to opt-out of fundraising solicitation and your decision will have no impact on your treatment or payment for services. If you do not want to be contacted for fundraising efforts, you must notify the Foundation at 201-291-6300 or by email at email@example.com. You may also opt-out of these communications by contacting the Foundation in writing at The Valley Hospital Foundation, 15 Essex Road, Suite 508, Paramus, NJ 07652.
- Hospital Directory. We are permitted to include certain limited information about you in The Valley Hospital's patient directory, if you are admitted as a patient to The Valley Hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. We will give you an opportunity to object to having this information included in The Valley Hospital patient directory. If you do not object, this directory information, except for your religious affiliation, may be released to people who call or come to the hospital and ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi. The hospital patient directory allows your family, friends and clergy to visit you during your stay at The Valley Hospital and generally know how you are doing.
- Individuals Involved in Your Care or Payment for Your Care. We are permitted to release protected health information about you to a family member or other individual involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are being treated by Valley Health System. In addition, we may disclose medical information about you during a disaster, such as to an entity helping with disaster relief effort so that your family can be notified about your condition, status and location. We will give you an opportunity to object to these disclosures.
- Research. Under certain circumstances, we may use and disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' needs for privacy of their medical information. Before we use or disclose your protected health information for research, the project will have been approved through this research approval process. We may, however, disclose information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the information they review does not leave Valley Health System.
- As Required By Law. We will use and disclose protected health information about you when required to do so by federal, state or local law or in response to a court order.
- To Avert a Serious Threat to Health or Safety. We may use and disclose protected health 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. Any disclosure, however, would be to someone able to help prevent the threat, and as otherwise permitted by applicable law.
- Business Associates. We may disclose protected health information about you to our vendors and contractors (our "business associates") that perform functions on our behalf or provide us with services, if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not permitted to use or disclose any information other than as specified in our contract or as otherwise permitted by federal, state or local law.
IV. SPECIAL SITUATIONS INVOLVING YOUR PROTECTED HEALTH INFORMATION.
- Organ and Tissue Donation. If you are or may be an organ donor, we may release your protected health 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.
- Military and Veterans. If you are a member of the armed forces, we may release your protected health information as required by military command authorities. We may also release such information about foreign military personnel to the appropriate foreign military authority.
- Workers' Compensation. We may release your protected health information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Public Health. We may disclose your protected health information for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- 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 who may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the healthcare 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 protected health information in response to a court or administrative order. We may also disclose such information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested, or pursuant to your authorization.
- Law Enforcement. We may release certain limited information about you if asked to do so by a law enforcement official, such as:
- in response to a 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 on our premises; 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 certain limited protected health information about you 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 such information about patients to funeral directors as necessary to carry out their duties.
- National Security and Intelligence Activities. We may release your protected health 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 protected health 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.
- Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with healthcare; (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.
V. SENSITIVE INFORMATION.
Certain state or federal laws may place more stringent requirements on the disclosure of your protected health information, which may be considered "Sensitive" and subject to special protections under applicable law, including, but not limited to HIV/AIDS, Genetic, Sexually Transmitted Diseases and Tuberculosis information, information related to emancipated care received by a minor, as well as Drug/Alcohol and Mental Health/Behavioral information originating from certain licensed facilities. For example, information related to emancipated care received by a minor may not be disclosed to the parents of the minor unless specifically authorized by the minor or applicable law.
Except to the extent we are required by applicable law to obtain a separate written authorization, we may use and disclose your protected health information, which contains Sensitive Information as permitted by this Notice. For example, we may use and disclose your Genetic information, Tuberculosis information or information regarding a Sexually Transmitted Disease as related to treatment, payment or healthcare operations activities described in this Notice, including through one or more HIEs. We may also use and disclose your HIV/AIDS related information to qualified personnel directly involved in your treatment or medical education, including through one or more HIEs, but we may not disclose such HIV/AIDS information for other purposes not specifically authorized by applicable law without your separate written authorization to do so.
VI. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding protected health information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care where it is maintained by us in one or more designated record sets. Usually, this includes medical and billing records but does not include psychotherapy notes. If we maintain such information electronically, you are also entitled to obtain such information in a reasonable electronic form and format (i.e., PDFs on a CD). To inspect and copy such information that may be used to make decisions about you, you must submit your request in writing. For medical records from The Valley Hospital, please write to the Health Information Management Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For medical records from Valley Medical Group, please write to the Privacy Officer, Valley Medical Group, 15 Essex Road, Suite 501, Paramus, NJ 07652. For medical records from Valley Home Care, please write to the Director of Quality, Valley Home Care, 15 Essex Road, Suite 301, Paramus, NJ 07652. If you request a copy of the information, we may charge a reasonable cost-based fee for copying, mailing or other supplies associated with your request.
- We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your protected health information, you may request, in writing, that the denial be reviewed. Another licensed healthcare professional chosen by Valley Health System will review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply with the outcome of the review.
- Parents and guardians may not have access to all of the information concerning a minor patient's care or treatment. For example, records related to emancipated care or treatment, which you may have received as a minor, such as related to pregnancy, sexually transmitted disease or certain mental health information, may not be made available to your parent or guardian without your consent unless state laws would authorize us to make such information available to your parent or guardian.
- Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to include additional information or amend your medical record. You have the right to request an amendment for as long as all the information, both old and new, is kept by or for Valley Health System. To request an amendment, your request must be made in writing and submitted to the Privacy Officer, Valley Health System, 15 Essex Road, Suite 501, Paramus, NJ 07652. 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. In addition, we may deny your request 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 information kept by or for Valley Health System;
- 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 protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing. For The Valley Hospital, please write to the Health Information Management Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For Valley Medical Group, please write to the Privacy Officer, Valley Medical Group,15 Essex Road, Suite 501, Paramus, NJ 07652. For Valley Home Care, please write to the Director of Quality, Valley Home Care, 15 Essex Road, Suite 301, Paramus, NJ 07652. Your request must state a time period, which may not be longer than six years from the date of your request. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional accounting of disclosures, 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 protected health information we use or disclose about you for treatment, payment or healthcare operations. We are not required to agree to your request in most cases. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or as required by law. We are required by law and will agree to restrict disclosure of your protected health information if your request pertains solely to a disclosure to a health plan when you have paid for services out-of-pocket and in full. For example, if you or a family member pay for a service completely out of pocket and ask us not to tell your insurance company about it, we will abide by this request.
- To request restrictions, you must make your request in writing. For The Valley Hospital, please write to the Patient and Family Relations Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For Valley Medical Group, please write to the Privacy Officer, Valley Medical Group, 15 Essex Road, Suite 501, Paramus, NJ 07652. For Valley Home Care, please write to the Director of Quality, Valley Home Care, 15 Essex Road, Suite 301, Paramus, NJ 07652. 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. For The Valley Hospital, please write to the Patient and Family Relations Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For Valley Medical Group, please write to the Privacy Officer, Valley Medical Group, 15 Essex Road, Suite 501, Paramus, NJ 07652. For Valley Home Care, please write to the Director of Quality, Valley Home Care, 15 Essex Road, Suite 301, Paramus, NJ 07652. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must tell us how or where you wish to be contacted. If you do not tell us how or where you wish to be contacted, we do not have to follow your request.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. 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 paper copy of this Notice at our website, www.ValleyHealth.com or by writing to the Privacy Officer, Valley Health System, 15 Essex Road, Suite 501, Paramus, NJ 07652.
- Right to be Notified of a Breach. You have the right and we will notify you of any breach of your unsecured protected health information.
- Right to Opt Out of HIEs. You may opt-out of having your protected health information shared through one or more HIEs as described in this Notice. If you do not want such information to be shared electronically through one or more HIEs, you must follow the opt-out procedures required for each HIE. Any opt-out you make will be honored once your opt-out has been processed. However, your information may still be shared through other mechanisms to the extent permitted or required by applicable law. Please visit our website at www.ValleyHealth.com for additional information about the HIEs that we participate in and about how you can exercise your right to not participate in one or more of these HIEs.
VII. CHANGES TO THIS NOTICE.
We reserve the right to change this Notice at any time. 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 at all of our locations. The Notice will contain on the first page the effective date. In addition, each time you register at or are admitted for treatment or healthcare services, we will offer you a copy of the current Notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with Valley Health System or with the Secretary of the Department of Health and Human Services at the Office of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278.
To file a complaint with Valley Health System, please write to or call the Privacy Officer, Valley Health System, 15 Essex Road, Suite 501, Paramus, NJ 07652.
You will not be penalized or retaliated against for filing a complaint.
IX. OTHER USES OF PROTECTED HEALTH INFORMATION.
Other uses and disclosures of information not covered by this Notice or the laws that apply to us will be made only with your written permission. Such information includes most (i) uses and disclosures of psychotherapy notes (if recorded by us); (ii) uses and disclosures of your protected health information for marketing purposes; (iii) disclosures that constitute a sale of your protected health information; and (iv) other uses and disclosures that may not be described in this Notice.
If you provide us permission to use or disclose such 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 protected health 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.
For further information, please write to the Privacy Officer, Valley Health System, 15 Essex Road, Suite 501, Paramus, NJ 07652. You may also contact the Privacy Officer by phone at 201-291-6329.