Robert R. Cawley, D.O.
Dover, NH 03802
EFFECTIVE DATE: April 14, 2003
REVISED: April 5, 2013
THIS JOINT NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. IT ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
When this Joint Notice refers to "we" or "us," it is referring to Wentworth-Douglass Hospital, the independent contractor members of its Medical Staff (including your physician), and other health care providers affiliated with Wentworth-Douglass Health System.
This Joint Notice describes how we will use and disclose your health information. The policies outlined in this Joint Notice apply to all of your health information generated by this organization, whether recorded in your medical record, invoices, payment forms, videotapes or other ways. Similarly, these policies apply to the health information gathered from other organizations by any health care professional, employee or volunteer who participates in your care.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
1. In some circumstances we are permitted to use or disclose your health information without obtaining your prior authorization and without offering you the opportunity to object. These circumstances include:
a. Uses or disclosures for purposes relating to treatment, payment and health care operations:
I. Treatment. We may use or disclose your health information for the purpose of providing, or allowing others to provide treatment to you. An example would be if your primary care physician discloses your health information to another doctor for the purpose of a consultation. Also, we may contact you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
II. Payment. We may use or disclose your health information for the purpose of allowing us, as well as other entities, to secure payment for the health care services provided to you. For example, we may inform your health insurance company of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care services provided to you.
III. Health Care Operations. We may use or disclose your health information for the purposes of our day-to-day operations and functions. We may also disclose your information to another covered entity, to allow it to perform its day-to-day functions, but only to the extent that we both have a relationship with you. For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided at this facility. We may also use your information to communicate with you about our own fundraising initiatives or allow our business associates to communicate with you for that purpose. YOU HAVE THE RIGHT TO INSTRUCT US NOT TO COMMUNICATE WITH YOU FOR FUNDRAISING PURPOSES. IF YOU WISH TO HAVE YOUR NAME REMOVED FROM OUR LIST TO RECEIVE FUNDRAISING MATERIALS TO SUPPPORT WENTWORTH-DOUGLASS HEALTH SYSTEM, PLEASE CONTACT OUR FOUNDATION OFFICE AT (603) 740-2687 OR E-MAIL US AT FOUNDATION@WDHOSPITAL.COM.
b. To create “de-identified information,” which is information regarding your care, but which does not include your name or other information that could be used to identify you;
c. When required by law;
d. For public health purposes;
e. To disclose information about victims of abuse, neglect, or domestic violence;
f. For health oversight activities, such as audits or civil, administrative or criminal investigations;
g. For judicial or administrative proceedings;
h. For law enforcement purposes;
i. To assist coroners, medical examiners or funeral directors with their official duties;
j. To facilitate organ, eye or tissue donation;
k. For certain research projects that have been evaluated and approved through a research approval process that takes into account patients' need for privacy;
l. To avert a serious threat to health or safety;
m. For specialized governmental functions, such as military, national security, criminal corrections, or public benefit purposes; and
n. For workers' compensation purposes, as permitted by law.
2. We may also use or disclose your health information in the following circumstances. Except in emergency situations, we will inform you of our intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object.
a. Directories. We may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific medical information about you. Except for your religion, we may disclose this information to any person who asks for you by name. We may disclose all directory information to members of the clergy.
b. Notifications. We may disclose to your relatives or close personal friends any health information that is directly related to that person's involvement in the provision of, or payment for, your care. We may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition, death, and to Organizations that are involved in those tasks during disaster situations.
3. Except as described above, your health information will be used and disclosed only with your written authorization. In particular:
a. Most uses and disclosures of psychotherapy notes require your written authorization. “Psychotherapy notes” are the personal notes of a mental health professional that analyze the contents of conversations during a counseling session. They are treated differently under federal law than other mental health records.
b. Uses and disclosures for marketing require your written authorization. “Marketing” is a communication that encourages you to purchase a product or service. However, it is not marketing if we communicate with you about health-related products or services we offer, as long as we are not paid by a third party for making that communication.
c. A disclosure that qualifies as a sale of your health information under federal law may not occur without your written authorization.
You may revoke your authorization at any time, in writing, unless we have taken action in reliance upon your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.
1. To Request Restrictions. You have the right to request restrictions on the use and disclosure of your health information for treatment, payment or health care operations purposes or notification purposes. We are not required to agree to your request, with one exception: If you have paid out of pocket and in full for a health care item or service, you may request that we not disclose your health information related to that item or service to a health plan for purposes of payment or health care operations. If you make such a request, we will not disclose your information to the health plan unless the disclosure is otherwise required by law. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment. To request a restriction, submit a written request to the Contact listed on the final page of this Joint Notice.
2. To Limit Communications. You have the right to receive confidential communications about your own health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only via e-mail or at work rather than at home. To request communications via alternative means or at alternative locations, you must submit a written request to the Contact listed on the final page of this Notice. All reasonable requests will be granted.
3. To Obtain a Copy of Health Information. You have the right to receive a copy of most health information about you. However, there are certain exceptions. For example, while you may ask to inspect or copy psychotherapy notes, federal law does not require your treating health care professional to provide them to you. Similarly, you do not have the right to a copy of information compiled in anticipation of or for use in civil, criminal, or administrative proceedings. To receive a copy of your records, you should submit a written request to the Medical Records Department of Wentworth-Douglass Hospital (for hospital records) or to your treating provider (for office records). If you request copies, you will be charged our regular fee for providing them.
Despite your general right to obtain a copy of your Protected Health Information, your request may be denied in some limited circumstances. For example, your request may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Your request may be denied if the Federal Privacy Act applies. A request for a copy of information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if providing a copy to you would reasonably be likely to reveal the source of the information. The decision to deny a request under these circumstances is final and not subject to review.
In addition, a request may be denied if (i) revealing the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your possession of that information would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and a licensed health care professional determines that your possession of the information would cause substantial harm to the patient or another individual. If a request is denied for these reasons, you have the right to have the decision reviewed by a health care professional who did not participate in the original decision. If your request is ultimately denied, the reasons for that denial will be provided to you in writing.
4. To Request Amendment. You may request that your health information be amended. Your request may be denied if the information in question: was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), is not part of our records, is not the type of information that would be available to you for inspection or copying (for example, psychotherapy notes), or is accurate and complete. If your request to amend your health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates. Requests to amend health information must be submitted in writing to the Contact listed on the final page of this Notice.
5. To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your health information made during the six-year period preceding the date of your request. However, the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out treatment, payment or health care operations, (ii) disclosures made to you, (iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure, (vi) disclosures that occurred prior to April 14, 2003 for the purpose of notifying your family or friends about your whereabouts, (vii) disclosures that occurred prior to April 14, 2003, (viii) disclosures made pursuant to an authorization signed by you, (ix) disclosures that are part of a limited data set, (x) disclosures that are incidental to another permissible use or disclosure, or (xi) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person's address (if known), and a brief description of the information disclosed and the purpose of the disclosure. To request an accounting of disclosures, submit a written request to the Contact listed on the final page of this Notice.
6. To a Paper Copy of this Joint Notice. You have the right to obtain a paper copy of this Notice upon request.
1. We are required by law to maintain the privacy of your health information and to provide you with this Joint Notice of our legal duties and privacy practices.
2. We are required to abide by the terms of this Joint Notice. We reserve the right to change the terms of this Joint Notice and to make those changes applicable to all health information that we maintain. Any changes to this Joint Notice will be posted on our website and at our facility and will be available from us upon request.
3. We are required to notify you in writing if we improperly use or disclose your health information in a manner that meets the definition of a “breach” under federal law. Although there are some exceptions, a breach generally occurs when health information about you is not encrypted and is accessed by, or disclosed to, an unauthorized person.
You can complain to us and to the Federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Contact set forth below. This Contact person will also provide you with further information about our privacy policies upon request. No action will be taken against you for filing a complaint.
DESIGNATED CONTACT PERSON:
Wentworth-Douglass Health System
789 Central Avenue
Dover, NH 03820
Telephone: (603) 742−5252
NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT BETWEEN HOSPITAL AND MEDICAL STAFF
Wentworth-Douglass Hospital, the independent contractor members of its Medical Staff (including your physician), and other health care providers affiliated with the Hospital have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations. This enables us to better address your health care needs in a clinically integrated setting. This notice is being provided to you as a supplement to the Joint Notices of Health Information Practices.
NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT BETWEEN HEALTH PARTNERS OF NEW HAMPSHIRE, INC., WENTWORTH-DOUGLASS HOSPITAL AND YOUR PHYSICIAN
Your physician participates in Health Partners of New Hampshire. Inc., an organization used by physicians and Wentworth-Douglass Hospital to help integrate the care you receive. The physicians participating in Health Partners of New Hampshire, Inc., along with the Hospital, have agreed to share your health information with one another as permitted by law for purposes of treatment, payment and health care operations. This enables us to better address your health care needs in a clinically integrated setting. This notice is being provided to you as a supplement to the Joint Notice of Privacy Practices already given to you.
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