Notice of Privacy Practices
Effective Date: November 1, 2011
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review the information in this notice carefully.
This Notice provides you with information to protect the privacy of your confidential health care information, hereafter referred to as protected health information (PHI). The Notice also describes the privacy rights you have and how you can exercise those rights. This Notice serves as a joint Notice from XMRI.COM and members of the XMRI.COM medical staff through an organized health care arrangement.
The Health Insurance Portability and Accounting Act (“HIPAA”) Privacy Rule controls the use and disclosure of what is known as Protected Health Information (“PHI”). Implementation of and compliance with this rule is not optional for our practice. We are required to give you the attached information. Please read and familiarize yourself with the attached material. Feel free to print out a copy for your records. Please indicate your receipt of this Notice below. It will be a permanent part of your medical record. If you are a parent or legal guardian of a patient, we will need a consent form signed by you for the patient.
Uses and Disclosures of Your Health Care Information
Your PHI may be used or disclosed for the following purposes based on your signing our Conditions of Admission Form which includes your acknowledgement of the Notice of Privacy Practices:
Treatment Purposes: Your PHI may be used by and disclosed to other health care professionals for the purpose of providing you with health care services. This may also include the need for us to obtain PHI from your previous health care providers. For example, information obtained by a nurse, physician or other member of your healthcare team will be recorded in your medical record and used to determine the course of treatment that should work best for you.
Health Care Operations: Your PHI may be used or disclosed for health care operations. Our staff members and independent contractors may have to access PHI for certain business operations and for quality improvement purposes. These uses and disclosures are necessary to operate XMRI.COM to help ensure that all of our patients receive quality care. For example, we may use PHI about your healthcare condition to review our treatment and services and to evaluate the performance of our staff in caring for you.
Business Associates: There are some services in our organization that are provided through contract with business associates. Your health care information may be used by or disclosed to our business associate(s) to provide and bill for services. These business associates will sign an agreement that requires them to have procedures in place to protect the privacy of your PHI.
Your PHI may be used or disclosed for the following purposes based on your opportunity to agree or object:
Patient Directory: Your PHI will be used to maintain a listing of the name, location, general condition and religious affiliation of patients in our facilities. The information may be disclosed to members of the clergy and to others who specifically request the information by identifying the patient by name. You may inform our Admissions staff or a caregiver if you choose to object to this use or disclosure.
Notification of and Communication with Family: Your PHI may be used or disclosed to notify or assist in notifying a family member, personal representative or another person responsible for your care of your location and general condition. Health professionals, using their judgment, may disclose to a family member or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.
Fund Raising: We may contact you as part of a fund raising effort for the hospital or an organization related to the hospital. We would only utilize contact information such as your name, address and telephone number and potentially the date(s) you received services from our organization. If you do not want to be contacted for fund raising efforts, you must notify our Privacy Officer, in writing, to object to this use or disclosure.
Your PHI may be used or disclosed for the following purposes without your consent, authorization or opportunity to agree or object:
As Required by Law: Your PHI will be used or disclosed when we are legally required to do so. If this occurs, we will limit the PHI used or disclosed to the minimum necessary to comply with the law.
Inmates: If you are an inmate, your PHI may be used or disclosed to the correctional institution or agents thereof when necessary for your health or the health and safety of others.
Emergencies: Your PHI may be used or disclosed in an emergency treatment situation. Your acknowledgement will be obtained as soon as practicable following the emergency.
To Avert a Serious Threat to Health or Safety: We may use and disclose PHI 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.
Organ Procurement Organizations: Consistent with applicable law, we may disclose PHI to organ procurement organizations for the purpose of organ and tissue donation and transplant.
Military: If you are or have been a member of the armed forces, we may release PHI about you as required by military command authorities.
Research: We may disclose PHI about you for research purposes when the research has been approved by an institutional review board and privacy protocols have been established.
Public Health Authorities: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, reporting births and deaths; reporting suspected abuse or neglect; and, reporting communicable disease information as required by public health authorities.
Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law, including, for example, audits, investigations, inspections, medical device reporting and licensure.
Lawsuits and Disputes: If you are involved in a lawsuit or 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 Officials: We may release PHI for law enforcement purposes as required by law or: 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 or during services being provided by XMRI.COM; and, in emergency circumstances to report a crime, the location of the crime or victim(s), or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: We may disclose PHI to coroners, medical examiners or funeral directors consistent with applicable law to allow these individuals to carry out their duties.
National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Your PHI may be used or disclosed for other purposes not identified above based on your signing a specific authorization form.
You can revoke this authorization at any time provided you submit the revocation in writing to the XMRI.COM Privacy Officer. However, XMRI.COM is unable to "take back" any uses or disclosures that were made pursuant to the authorization prior to its revocation.
Your Health Information Rights
Right to Request a Restriction of Uses and Disclosures: You have the right to request a restriction on our use and disclosure of your PHI. To request restrictions, you must make your request, in writing, to our Privacy Officer. In your request, you must tell us (1) what information you want to restrict; (2) whether you want to restrict our use, disclosure or both; and (3) to whom you want the restrictions to apply, for example, disclosures to your spouse. A Request form is available for you to complete to make this request or you can write our Privacy Officer directly. A member of our staff can provide the request form for you. By law, we are not required to grant your request. We will notify you, in writing, whether we will grant or deny your request. The restriction(s), if granted, would not apply if you need emergency treatment and the information is needed to provide that treatment. If your request is granted, we may choose, at a later date, to deny continuing the restriction and if so, we will notify you in writing of that decision.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location to protect the confidentiality of the information. 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 to our Privacy Officer. We cannot ask you the reason for such a request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. A Request form is available for you to complete to make this request or you can write our Privacy Officer directly. A member of our staff can provide the request form for you.
Right to Inspect and Copy: You have the right to request to inspect and obtain a copy of your PHI. There are a few exceptions to this right such as psychotherapy notes. To request to inspect and obtain a copy of your PHI, you must submit your request, in writing, to our Privacy Officer. We must approve or deny your request within 30 days of receipt of the request and in the case of denial, provide you an explanation of the reason for the denial. For copies of your PHI, we may charge a reasonable fee for copying, postage (if mailed) and other costs associated with your request. XMRI.COM has sixty (60) days to respond to your request if the records are maintained off-site.
Right to Amend: You have the right to request that we amend your PHI that we created if you feel that the information is incorrect or incomplete. To request an amendment, you must submit the request, in writing, to our Privacy Officer. You must also provide reasoning to support your request. If you make such a written request, we will act on your request and respond to you, in writing, within 60 days of receipt of the request. Your request for an amendment may be denied if the request 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 (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the information kept by or for us; (3) is not part of the information which you would be permitted to inspect or copy; or (4) is accurate and complete.
Right to Receive an Accounting of Disclosures: You have the right to request that we provide you with an accounting of certain disclosures of your PHI. To request an accounting, you must submit your request, in writing, to our Privacy Officer. Standard disclosures such as disclosures to you or disclosures for treatment, payment and health care operations would not be included in the accounting. Your request must state a time period for the accounting. The accounting may not be for a period greater than six years and may not include dates prior to April 14, 2003. Your request should indicate in what form you want the accounting (for example, on paper, electronically). The first accounting in a 12-month period is free. We may charge a reasonable fee for additional accountings in the same 12-month period.
Right to Receive a Paper Copy of this Notice: You have a right to receive a paper copy of our Notice of Privacy Practices. You may obtain a copy of this notice at our website, www.XMRI.com or, to obtain a paper copy, please inquire at the Information Desk or Admissions.
Right to File a Complaint: You have the right to file a complaint if you believe we are not in compliance with our Notice of Privacy Practices and the Healthcare Information Portability and Accountability Act (HIPAA) or if you believe your privacy rights have been violated. Your complaint can be submitted, in writing, to our Privacy Officer. Your complaint can be anonymous. We value your opinion and we will not retaliate against you in any manner for filing a complaint. You also have a right to file a complaint with the Secretary of the Department of Health and Human Services.
A. We intend to use and disclose PHI in the additional following ways:
B. The Law requires that we have privacy protections for Protected Health Information and to give
you Notice of our legal responsibilities to individuals.
C. We have to follow the terms and conditions contained in this Notice of Privacy Practices.
D. We retain the right to make retroactive and non-retroactive changes to the Notice of Privacy
Practices. This means that if we make retroactive revisions to the Notice of Privacy Practices and thus change our Privacy Policies and Procedures we may apply those changes to PHI we received, obtained and created prior to those changes if we choose and state so in the Notice. If we make non-retroactive revisions to the Notice of Privacy Practices and thus change our Privacy Policies and Procedures we will apply those changes to PHI we receive, obtain and create in the future.
E. Any individual who would like a copy of any revised Notice of Privacy Practices shall submit such request, in writing, to our Privacy Officer.
For More Information
If you have any questions or would like further information about this Notice, please contact our Chief Information Officer and Privacy Officer:
309 Fellowship Road Suite 200
Mt. Laurel NJ 08054