Notice of Bayhealth's Privacy Practices
Effective April 14, 2003
If you have any questions about this Notice, or to obtain a copy of this Notice, please contact our Privacy Officer at (302) 744-6728.
Who Will Follow This Notice
This Notice describes our hospital’s practices and that of:
The Medical Staff of the Hospital and any other health care professionals authorized to enter information into your hospital record.
All departments and units of the Hospital.
All employees, staff, trainees, students, volunteers and contractors.
All affiliated entities of Bayhealth Medical Center including all sites and service locations.
These affiliated entities, sites and service 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.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital. We need this record to provide you with care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
This Notice will tell you about the ways we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
Make sure 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.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we 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 medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, students, or other hospital personnel who are involved in taking care of you at Bayhealth Medical Center. We may also disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital.
For Payment: We may use and disclose medical information about you so the treatment and services you receive at Bayhealth Medical Center may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Bayhealth Medical Center and to help ensure that our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may disclose information to doctors, nurses, technicians, students, and other hospital personnel for review and learning purposes. We may combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.
State Confidentiality Laws: Certain state and other federal laws provide even greater protection for medical records of a sensitive nature, including HIV related records, some sexually transmitted disease records, genetic information records, records of alcohol or substance abuse treatment, mental health treatment records, and some records regarding reproductive rights. We will use and disclose your health information only in accordance with the more restrictive laws that provide more protection for records included in these categories.
Business Associates: We may disclose medical information to “business associates” who provide contracted services such as accounting, legal representation, claims processing, accreditation, and consulting. If we do disclose medical information to a business associate, we will do so subject to a contract that provides that the information will be kept confidential.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder of 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 alternatives that may be of interest to you.
Health Related Benefits and Services: We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you.
Fund-raising Activities: Bayhealth Medical Center may contact a patient to request financial support for Bayhealth programs. We would only release information such as your name, address, telephone number and the dates of treatment. If you do not wish to be contacted for fund-raising efforts, please notify the Privacy Officer, 640 South State Street, Dover, Delaware 19901 in writing.
Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (good, fair, serious or critical) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care, or in payment activities related to your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so your family can be notified about your condition, status and location.
As Required by Law: We will disclose medical information about you when required to do so by federal, state or local law.
Research: In most cases, we will ask for your written authorization before using your information or sharing it with others in order to conduct research. Under some circumstances, we may use and disclose your health information without your authorization if we obtain approval through a special approval process to ensure that research without your authorization poses a minimal risk to your privacy. Under no circumstances would we allow researchers to use your name or identity publicly.
Organ and Tissue Donation – We may release medical 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 medical information about you as required by military command authorities. We may also release information to components of the Department of Veterans Affairs to determine whether you are eligible for certain benefits.
Workers’ Compensation – We may release medical information about you for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks – We may disclose information about you for public health activities. These activities generally include the following:
Prevent or control disease, injury or disability;
Report births and deaths;
Report abuse, neglect or the need for protective services;
Report reactions to medications or problems with products;
Notify people of recalls of products they may be using;
Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
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 medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, 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.
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. 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.
Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical 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.
Law Enforcement – We may release 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;
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 deceased patients of the hospital to funeral directors as necessary for them to carry out their duties.
National Security and Intelligence Activities – We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
To Avert a Serious Threat to Health or Safety – We may use and disclose medical information about you when we determine it is 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 only be to someone able to help prevent the threat.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and to receive a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.
You must submit your request in writing to Bayhealth Health Information Management. 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.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to information, you may request that the denial be reviewed.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to Bayhealth Health Information Management. In addition, you must provide a reason that supports your request. We may deny your request for the amendment 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 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 an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of medical information about you. The list does not include uses and disclosures that have been made for treatment, payment, or health care operations, or disclosures that were made with your authorization or consent. To request this list or accounting of disclosures, you must submit your request in writing to Bayhealth Health Information Management. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. 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, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer at Bayhealth Medical Center. 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. To request confidential communications, you must make your request in writing to the Privacy Officer at Bayhealth Medical Center. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
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 at any time. You may obtain a copy of this Notice at our website at www.bayhealth.org. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a copy, contact the Privacy Officer at Bayhealth Medical Center.
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. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, 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 Bayhealth Medical Center or with the Office for Civil Rights, U.S. Department of Health and Human Services. All complaints regarding your privacy rights must be submitted in writing to the Privacy Officer, and in no way will affect the quality of care you receive. You will not be penalized for filing a complaint.
Submit complaints in writing to:
Bayhealth Medical Center
640 South State Street
Dover, Delaware 19901
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 we are required to keep records of the care that we provided to you.