April 14, 2003
JOINT NOTICE OF PRIVACY
THE GOOD SAMARITAN HEALTH SERVICES FOUNDATION
(Including The Good
Samaritan Hospital, GSH Dialysis, Inc., GSH Emergency Medical Transport, GSH
Home Med Care, Inc., GSH Urgent Care, Inc., doing business as ("d/b/a") Priority
Care, Good Samaritan Homemaker Home Health Aide Agency, Inc., Lebanon MRI
Associates Ltd. d/b/a GSH Imaging Center, Lebanon Outpatient Surgical Center,
LP, Professional Financial Services, Inc., and Good Samaritan Physician
Services, collectively "System")
I. 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.
This notice describes our System's
practices and that of:
- Any health care
professional authorized to enter information into your patient record.
- All departments and units of the health
- Any member of a volunteer group we allow to
help you while you are in the System.
- All employees, staff members, independent
contractors, volunteers, representatives or agents of System.
II. WE HAVE A LEGAL DUTY
TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
We are legally required to
protect the privacy of your health information. We call this
health information, or PHI for short, and it includes information that can be
used to identify you that we have created or received about your past, present,
or future health or condition, the provision of health care to you, or the
payment of this health care. We must provide you with this notice about our
privacy practices that explains how, when, and why we use and disclose your PHI.
With some exceptions, we may not use or disclose any more of your PHI than is
necessary to accomplish the purpose for the use or disclosure. We are legally
required to follow the privacy practices that are described in this
However, we reserve the
right to change the terms of this notice and our privacy policies at any time.
Any changes will apply to the PHI we already have. Before we make an important
change to our policies, we will promptly change this notice and post a new
notice in clear and prominent locations. The notice will contain on the first
page, in the top right-hand corner, the effective date. You can also request a copy of this notice
from the contact person listed in Section VI (Privacy Officer), below, at any
time and can view a copy of the notice on our Web site at
III. HOW WE MAY USE AND
DISCLOSE YOUR PROTECTED HEALTH INFORMATION.
We use and disclose
protected health information for many different reasons. For some of these uses
or disclosures, we need your specific authorization. Below, we describe the most
common categories of our uses and disclosures and give you some examples of each
A. Uses and Disclosures
Relating to Treatment, Payment, or Health Care Operations.We may use and
disclose your PHI for the following reasons:
For treatment. We may disclose your PHI to physicians, nurses, medical
students, and other health care personnel who provide you with health care
services or are involved in your care. For example, if you're being treated for
a knee injury, we may disclose your PHI to the physical rehabilitation
department in order to coordinate your care.
To obtain payment for treatment. We may use and disclose your PHI in
order to bill and collect payment for the treatment and services provided to
you. For example, we may provide portions of your PHI to our billing department
and your health plan to get paid for the health care services we provided to
you. Under certain circumstances, we may also provide your PHI to our business
associates, such as billing companies, claims processing companies, and others
that process our health care claims.
For health care operations. We may use and disclose medical information
about you for System operations. For example, we may use your PHI in order to
evaluate the quality of health care services that you received or to evaluate
the performance of the health care professionals who provided health care
services to you. Under certain circumstances, we may also provide your PHI to
our accountants, attorneys, consultants, and others in order to make sure we are
complying with the laws that affect us.
B. Certain Uses and
Disclosures Do Not Require Your Authorization.We may use and disclose your
PHI without your authorization for the following reasons:
When a disclosure is required by federal, state, or local law, judicial or
administrative proceedings, or law enforcement. For example, we make
disclosures when a law requires that we report information to government
agencies and law enforcement personnel about victims of abuse, neglect, or when
dealing with gunshot and other wounds; or when ordered in a judicial or
For public health activities. For example, we report information about
births, deaths, and various diseases to government officials in charge of
collecting that information, and we provide coroners, medical examiners, and
funeral directors necessary information relating to an individual's
For health oversight activities. For example, we will provide information
to assist the government when it conducts an investigation or inspection of a
health care provider or organization.
For purposes of organ donation. We may notify organ procurement
organizations to assist them in organ, eye, or tissue donation and
For research purposes. In certain circumstances, we may provide PHI in
order to conduct medical research.
To avoid harm. In order to avoid a serious threat to the health or safety
of a person or the public, we may provide PHI to law enforcement personnel or
persons able to prevent or lessen such harm.
For specific government functions. We may disclose PHI of military
personnel and veterans in certain situations. And we may disclose PHI for
national security purposes, such as protecting the president of the United
States or conducting intelligence operations.
For workers' compensation purposes. We may provide PHI in order to comply
with workers' compensation laws.
Appointment reminders and health-related benefits or services. We may use
PHI to provide appointment reminders or give you information about treatment
alternatives or other health care services or benefits we offer.
Fundraising activities. We may use PHI to raise funds for our
organization. The money raised through these activities is used to expand and
support the health care services and educational programs we provide to the
community. If you do not wish to be contacted as part of our fundraising
efforts, please contact the Privacy Officer.
C. Two Uses
and Disclosures Require You to Have the Opportunity to
Patient directories. We may include your name, location in a facility
within this system, general condition, and religious affiliation in our patient
directory for use by clergy and visitors who ask for you by name unless you
object in whole or in part. The opportunity to consent may be obtained
retroactively in emergencies.
Disclosures to family, friends, or others. We may provide your PHI to a
family member, friend, or other person that you indicate is involved in your
care or the payment for your health care, unless you object in whole or in part.
The opportunity to consent may be obtained retroactively in emergency
D. All Other Uses and
Disclosures Require Your Prior Written Authorization. In any other situation
not described in Sections IIIA, B, and C, above, we will ask for your written
authorization before using or disclosing any of your PHI. If you choose to sign an authorization to
disclose your PHI, you can later revoke that authorization in writing to stop
any future uses and disclosures 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.
IV. WHAT RIGHTS YOU HAVE
REGARDING YOUR PHI.
You have the following
rights with respect to your PHI:
A. The Right to Request
Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how
we use and disclose your PHI. We will consider your request but are not legally
required to accept it. If we accept your request, we will put any limits in
writing and abide by them except in emergency situations. You may not limit the
uses and disclosures that we are legally required or allowed to make. To request restrictions, you must make your
request in writing to the Privacy Officer. 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.
B. The Right to Request
Confidential Communications. You
have the right to ask that we
communicate your PHI to you by alternative means or at alternative locations.
For example, sending information to
your work address rather than your home address. We will honor your request so long as we can
easily provide it in the format you requested. To request confidential communications, you
must make your request in writing to the responsible party that will be
contacting you with information. Your
request must specify how or where you wish to be contacted.
C. The Right to Request
to See and Get Copies of Your PHI.
In most cases, you have the right to look at or get copies of your PHI that we
have. Usually, this includes medical and
billing records, but does not include psychotherapy notes. To inspect and/or receive copies of medical
information that may be used to make decisions about you, you must submit your
request in writing to the Privacy Officer. If we do not have your PHI but we
know who does, we will tell you how to get it. We will respond to you within 30
days after receiving your written request. In certain situations, we may deny
your request. If we do, we will tell
you, in writing, our reasons for the denial and explain your right to have the
denial reviewed. In the event you
request that the denial be reviewed, another licensed health care professional
chosen by the Privacy Officer 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.
If you request copies of
your PHI, we may charge a fee for the costs of copying, mailing or other
supplies associated with your request. Instead of providing the PHI you
requested, we may provide you with a summary or explanation of the PHI as long
as you agree to that and to the cost in advance.
D. The Right to Request
a Listing of the Disclosures We Have Made. You have the right to get a list of certain
instances in which we have disclosed your PHI. The list will not include uses or
disclosures as described in Section IIIA, B, and C. The list also will not
include uses and disclosures made for national security purposes, to corrections
or law enforcement personnel, or before April 14, 2003.
To request this list of
instances in which we have disclosed your PHI, you must submit your request in
writing to the Privacy Officer. Your
request must state a time period, which may not be longer than six years and may
not include dates before April 14, 2003.
We will respond within 60 days of receiving your request. The list we will give
you will include the date of the disclosure, to whom PHI was disclosed
(including their address, if known), a description of the information disclosed,
and the reason for the disclosure. We will provide the list to you at no charge,
but if you make more than one request in the same year, we may charge you for
the costs of providing the list.
E. The Right to Request
a Correction or an Update to Your PHI. If you believe that there is a mistake in
your PHI or that a piece of important information is missing, you have the right
to request that we correct the existing information or add the missing
information. You must provide the request and your reason for the request in
writing to the Privacy Officer. We will respond within 60 days of receiving your
request. We may deny your request in writing if the PHI is (i) correct and
complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not
part of our records. Our written denial will state the reasons for the denial
and explain your right to file a written statement of disagreement with the
denial. If you do not file one, you have the right to request that your request
and our denial be attached to all future disclosures of your PHI. If we approve
your request, we will make the change to your PHI, tell you that we have done
it, and tell others that need to know about the change to your PHI.
F. The Right to Request
a Paper Copy of this Notice.You have the right to request a paper copy of
this notice. If you have received this
notice electronically, you may still receive a paper copy by contacting the
Privacy Officer. You may also obtain a copy of this notice at our website,
V. HOW TO COMPLAIN ABOUT
OUR PRIVACY PRACTICES.
If you think that we may
have violated your privacy rights, you may file a complaint with the Privacy
Officer. All complaints must be in writing. You also may send a written complaint to
Region III, Office for Civil Rights, U.S. Department of Health and Human
Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building,
Philadelphia, PA 19106-9111. Complaints
to the Secretary must identify the entity about which the complaint is being
made, must describe the situation that gives rise to the complaint, and must be
filed within 180 days of the date when the complainant knew, or should have
known, of the event that gave rise to the complaint. We will take no retaliatory action against
you if you file a complaint about our privacy practices.
VI. PERSON TO CONTACT
FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY
If you have any questions
about this notice or any complaints about our privacy practices, or would like
to know how to file a complaint with the Secretary of the Department of Health
and Human Services, please contact:
Good Samaritan Hospital
Fourth and Walnut Streets
Lebanon, PA 17042