Protecting your medical information is an important priority for Emerson Hospital. This notice describes the way Emerson Hospital may use and share your medical information and how you can obtain access to this information. It also describes your rights, as well as certain obligations that we have relative to your medical information. Please read it carefully.
ABOUT YOUR PRIVACY
An overview of patient privacy at Emerson Hospital
This document describes the way Emerson Hospital may use and share your medical information and how you can obtain access to this information. It also describes your rights, as well as certain obligations that we have relative to your medical information. Please read it carefully.
What this document covers
This document describes the privacy practices of:
• Emerson Health Systems, Inc. and its related entities. Please refer to Emerson Hospital’s website (www.emersonhospital.org) for a full listing
• Any health care professional authorized to enter information into your medical record on behalf of Emerson and these entities
• All departments and units of these entities
• Any member of a volunteer group we allow to help you while you are in the hospital
• All employees, staff and other personnel.
Our privacy obligations to you
Protecting your medical information is an important priority for Emerson Hospital. This document explains what information we collect, with whom we share it and how you can direct us not to share information with certain parties. We are required by law to:
• Maintain the privacy of your health and medical information
• Provide you with this document describing our legal duties and privacy practices
• Follow the terms described in this document
• Notify you following a security breach that affects protected health information.
Understanding your medical record and information
Each time you visit a hospital, physician or other health care provider, a record of your visit is generated. This record typically includes your symptoms, medical history, examination, test results, diagnoses, treatment and a plan for future care or treatment. This information is your health or medical record, and it serves as a:
• Basis for planning your care and treatment
• Means of communication among the health professionals who contribute to your care
• Legal document describing the care you received
• Way for you or a third-party payer to make sure billed services were actually provided
• 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 we can assess and continually use to improve the care we provide and the outcomes we achieve.
Understanding what is in your record and how your health information is used can help you to:
• Make sure it is correct
• Better understand who, what, when, where and why others may obtain your health information
• Make more informed decisions when authorizing disclosures to others.
How we may use and share your medical information
The following describes the ways Emerson is permitted to use and share medical information.
Treatment. In addition to using your medical information to provide you with necessary medical treatment or services, we may share this information about you with physicians, nurses, technicians or other health care personnel who care for you at Emerson or outside of Emerson. This includes providers at our associated facilities or office locations. A list of our associated facilities can be found at www.emersonhospital.org.
In addition, we also may share your medical information with people who are involved in maintaining your health or well-being during your hospital stay, as well as after you are discharged. This might include family members, friends, home health services, support agencies or clergy. Our goal is to make sure that everyone caring for you has the information they need.
Emerson Hospital participates in a Health Information Exchange—often referred to as a HIE—which is a secure electronic network that allows us to efficiently share your personal health information with authorized providers who care for you. This is particularly useful during an emergency, because it provides immediate access to information about your medications, allergies and existing health problems, and in general makes caring for you more efficient.
Authorized providers who participate in the network can share key clinical information electronically, which reduces phone calls, scanning and faxing between Emerson and physician offices. Those providers are trained to handle your personal health information with the utmost confidentiality, and they commit to doing so.
Payment. We may use and share your medical information so that the treatment and services you receive can be billed and payment collected from you, an insurance company or a third party. In some cases, we will inform your health plan about a treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment. We also may provide information to a third party who helps pay for your care.
Health care operations. We may use and share your medical information for health care operations—activities that are necessary to run the hospital or physician office and assure that our patients receive quality care. We sometimes combine medical information from many patients, which is useful in making decisions about additional services Emerson should offer, services that are not needed and whether certain new treatments are effective.
We also may share information with physicians, nurses, technicians and other personnel for review and educational purposes. Information that identifies you may be removed so that it can be used to study health care and health care delivery without revealing specific patients. Examples of health care operations include:
• Monitoring the quality of care and making improvements where needed
• Making sure health care providers are qualified to perform their jobs
• Reviewing medical records for completeness and accuracy
• Meeting standards set by regulating agencies, such as The Joint Commission
• Teaching health professionals
• Using outside business services, such as transcription, storage, auditing or legal services
• Storing your health information on computers
• Managing and analyzing medical information.
Other ways we may use and share your health information
Communication with you. Emerson may use and share medical information to contact you as a reminder that you have an appointment. We also may use it for registration/insurance updates, billing or payment matters, pre-procedure assessment or test results.
Treatment alternatives. We may use and share medical information to inform you about or recommend possible treatment options or health-related benefits that may interest you.
Workers’ compensation. We may release your medical information to workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Public health activities. When requested, we may share your medical information for public health activities:
- 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 notify people of recalls of products they may be using
- to notify someone who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Fundraising activities. Emerson may use your demographic information—such as name, address, phone number, age, gender, dates of service, department or service, treating physician or outcome information—to contact you as part of its fundraising efforts. If you do not wish to be contacted, you may inform our Development Office at 978-287-3080.
Hospital directories. We may include certain limited information about you in the hospital directory while you are an inpatient at Emerson. This typically includes your name, location in the hospital, your general condition (such as good, fair, etc.) and your religious affiliation. This information, except for your religious affiliation, also may be given to members of your family, friends and others 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 inform the registration staff. You also may ask to limit the information about you that is provided. If you are experiencing a medical emergency and not able to make your wishes known, we will include this information in the directory if we consider it to be in your best interest. For example, in disaster situations where there are multiple casualties, we may release general information, such as: the hospital is treating four individuals from the accident.
Disclosures to family, friends or others. We may share relevant health information about you with a family member or other person who is close to you if they are involved either in your care or payment of your care. We may use or share your health information—specifically, your location, general medical condition or death—to notify a family member or other person who is responsible for you. If you are able to make health care decisions, we will ask if you want Emerson to share this information with your family members or others.
If you are having a medical emergency and not able to make your wishes known, we will use our best judgment to decide whether to share information. However, if we believe it is in your best interest, we will only share essential information. Note that we also may use or share your health information with a public or private agency that is assisting in disaster relief with the goal of coordinating efforts to notify someone on your behalf. If we can reasonably do so during the emergency, we will attempt to obtain your permission before sharing this information.
Research. We may use or share your medical information for research purposes if our Institutional Review Board, which oversees clinical research, approves a waiver of authorization for such use.
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 share your medical information when it is necessary to prevent a serious threat to your health and safety or that of the public or another person. Any disclosure would be for the purpose of helping to prevent the threat.
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 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.
Health oversight activities. We may, when requested, provide your medical information to a health oversight agency for activities authorized by law, such as audits, certifications, investigations, inspections and licensure. These activities assist the government in monitoring the health care system, government programs and in complying with civil rights laws.
Lawsuits and disputes. If you are involved in a lawsuit or dispute, we may share your medical information in response to a court order. Under certain circumstances, we also may share your medical information in response to a subpoena or other lawful process. We will do so only if efforts have been made to inform you of the request, to obtain an order protecting the information requested or if you or a court have given written authorization.
Law enforcement. If permitted by law, we may release your medical information if asked to do so by a law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process
- to identify or locate a suspect, fugitive, material witness or missing person
- in reference to the victim of a crime if, under certain, limited circumstances, we are unable to obtain the person’s agreement
- in reference to a death we believe may be the result of criminal conduct
- in reference to criminal conduct at our facility
- 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 to identify a deceased person or determine the cause of death. We also may release medical information about Emerson patients to funeral directors or their designees as necessary to carry out their services.
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, as authorized by law.
Protective services for the President and others. If permitted by law, we may provide your medical information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.
Inmates. We may release medical information about inmates of a correctional institution or under the custody of a law enforcement official under certain circumstances if permitted by law. This release would be necessary (1) for the institution to provide the inmate with health care; (2) to protect the inmate’s health and safety or that of others; or (3) for the safety and security of the correctional institutional.
Uses or disclosures of information that require your written permission
Using and/or sharing health information for most purposes other than treatment, payment or health care operations requires your specific authorization. The following will occur only with authorization from the individual:
- most uses and disclosures of psychotherapy notes
- uses and sharing of personal health information for marketing purposes, including communications related to subsidized treatment
- disclosures that constitute a sale of personal health information
- other uses and disclosures not described in this document.
Certain information that may be contained in your medical record is considered by state and federal law to be highly sensitive. This includes, but is not limited to:
- HIV/AIDS testing or test results
- behavioral health documentation
- sexually transmitted diseases
- certain genetic information.
Such sensitive information has additional protection from disclosure; often, your written authorization is required even before disclosure for treatment, payment or health care operations. There are some limited exceptions to these rules where your permission is not necessary before the use/disclosure of sensitive information.
If you are asked, and give, written permission for the use and/or disclosure of your health information, you may withdraw such consent at any time, in writing, except when providers have already acted upon your previously provided consent.
Your rights regarding your health information
You have the following rights regarding health information that Emerson Hospital maintains about you.
Right to inspect and copy. With certain exceptions, you have the right to inspect and/or receive a copy of your health information. Such requests usually include medical and billing records but not psychotherapy notes.
To inspect and/or receive a copy of your health information, please submit your request in writing to: Emerson Hospital, Medical Records Department, Release of Information Section, 133 ORNAC, Concord, MA 01742. Note that, if you request a copy of the information, you may be charged a fee.
For copies of your physician's office records, please contact your physician's office directly.
There are limited circumstances where we may deny your request to see and obtain a copy of your health information. If you are denied access, you may request that the denial be reviewed by a secondary provider. Emerson will comply with the result of the review. We may offer to provide you with a summary or explanation of the information you requested, as long as you agree in advance to this and to any associated fees.
Right to request an amendment. If you feel that Emerson has health information about you that is incorrect or incomplete, you may request that we amend the information for as long as it is kept by or for the hospital. Your request for an amendment will become a legal part of your medical record and will be sent out with the rest of the record whenever a request for a copy is received. No part of the original documentation in your medical record can be changed, deleted or destroyed.
To request an amendment, please send it, in writing, to: Emerson Hospital, Medical Record Department, Privacy Officer, 133 ORNAC, Concord, MA 01742. Note you also must provide a reason that supports your request for the change. Emerson has 60 days to respond to your request.
To request an amendment of your physician's office record, please contact your physician's office directly.
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 that we amend information that:
- was not created by Emerson Hospital
- was created by a person or entity no longer available to make the amendment
- is not part of the information which you would be permitted to inspect and copy
- is accurate and complete in the record.
If we grant your request, we will ask that you inform us of the individuals you wish to receive the changes. You must agree to have Emerson notify them along with any others who received the information before corrections were made, and who may have relied on incorrect information in providing you with treatment.
Right to an accounting of disclosures. You have the right to receive a list of certain disclosures we have made of your health information, either without obtaining an authorization or for purposes of treatment, payment or health care operations.
To request this accounting of disclosures, please submit your request in writing to: Emerson Hospital, Medical Record Department, Release of Information Section, 133 ORNAC, Concord, MA 01742. Your request must include a time period no longer than the six previous years. You are entitled to one such accounting within any 12- month period at no cost. If you request a second accounting within that same 12- month period, there will be a charge.
The following will not be included in a list of disclosures:
- sharing your medical information for the purpose of treatment, payment or health care operations
- sharing your medical information if you gave permission in writing
- sharing information in the facility’s directory
- sharing information with a person involved in your care
- using your information to communicate with you about your health
- sharing information for national security intelligence purposes or with correctional institutions or law enforcement officials who have custody of you.
To request a list of disclosures from your physician office record, please contact your physician's office directly.
Right to request restrictions. You have the right to request a restriction or limitation on the health information we use or share about you for treatment, payment or health care operations. In addition, you have the right to request a limit on the health information we share about you with 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 you with emergency treatment. You may not ask that we restrict uses and sharing of information that are legally required.
The following exception may apply:
If you pay for a health care product or service in full yourself (out of pocket), you may request that we not share any information about that with your health plan for purposes of carrying out payment or health care operations. Note that this restriction will not apply to disclosures for the purpose of carrying out treatment. If we do agree, we will put the restriction in writing and abide by it, unless you need to be treated in an emergency. However, Emerson cannot agree with any request that would prevent the hospital from disclosing information when it is legally required to do so.
To request a restriction, please make your request in writing to: Emerson Hospital, Medical Records Department, Privacy Officer, 133 ORNAC, Concord, MA 01742. In your request, you must describe: (1) what information you wish 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, only to you and 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 may ask that we contact you only at home or only by mail.
To request confidential communications, please make your request in writing to: Emerson Hospital, Medical Records Department, Privacy Officer, 133 ORNAC, Concord, MA 01742. We are happy to accommodate all reasonable requests. Please indicate how or where you wish to be contacted.
Right to a paper copy of this document. You have the right to receive a paper copy of this document. You may request that Emerson provide you with a copy of this document at any time. Copies are available through Emerson Hospital or at our website, www.emersonhospital.org.
Emerson Hospital is required by law to keep your health information private. We also are required to give people notice of our legal duties and privacy practices with respect to their health information.
Emerson maintains medical records for 20 years after an individual’s discharge or final treatment; other records are maintained in accordance with state and federal regulations. A copy of Emerson's retention policy for medical records is available upon request.
Changes to this document. We reserve the right to change this document and make the revision or change effective relative to your current medical information, as well as any information we receive in the future. We will post a copy of the current document at the hospital. Each time you register or are admitted to Emerson Hospital for treatment or health care services, either as an inpatient or outpatient, you may request a copy of the document currently in effect.
Complaints. If you believe your privacy rights have been violated, or you disagree with any action Emerson has taken with regard to your health information, we encourage you, your family or your guardian to speak with us. Note that, if you present a complaint, your care will not be affected in any way. Our goal is to provide you with the best care while always respecting your privacy.
You may file a complaint with the hospital or with:
Secretary of the Department of Health and Human Services
J.F.K. Federal Building, Room 1875
Boston, MA 02203
Voice mail: 617-565-1340 or email: OCRComplaint@hhs.gov.
To file a complaint with Emerson Hospital:
Quality and Patient Safety Department
Medical Record Department
Please send your privacy requests in writing to:
Concord, MA 01742
This privacy document is effective as of April14, 2003
Reviewed and revised January 2011; September 2013