Revised: September 23, 2013
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.
Holy Cross Health is required by the Health Insurance Portability and Accountability Act of 1996, and the Health Information Technology for Economic and Clinical Health Act (found in Title XIII of the American Recovery and Reinvestment Act of 2009) (collectively referred to as “HIPAA”), as amended from time to time, to maintain the privacy of individually identifiable patient health information. This information is “protected health information” and is referred to as “PHI”. We are also required to provide patients with a Notice of Privacy Practices regarding PHI. We will only use or disclose your PHI as permitted or required by Maryland law. This Notice applies to your PHI in our possession including the medical records generated by us.
Holy Cross Health understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how we will use and disclose your PHI.
This Notice applies to the delivery of health care by Holy Cross Health and its medical staff in the hospital, outpatient departments and clinics. This Notice also applies to the utilization review and quality assessment activities of CHE Trinity Health and Holy Cross Health as a member of CHE Trinity Health, a Catholic health care system with facilities located in multiple states throughout the United States.
I. Permitted Use or Disclosure
Holy Cross Health will use and disclose your PHI to provide, coordinate, or manage your health care and related services to carry out treatment functions. The following are examples of how Holy Cross Health will use and/or disclose your PHI:
- To your attending physician, consulting physician(s), and other health care providers who have a legitimate need for such information in your care and continued treatment.
- To coordinate your treatment (e.g., appointment scheduling) with us and other health care providers by disclosing information such as name, address, employment, insurance carrier, etc.
- To contact you as a reminder that you have an appointment for treatment or medical care at our facilities.
- To provide you with information about treatment alternatives or other health-related benefits or services.
- If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Holy Cross Health will disclose your PHI to the correctional institution or law enforcement official.
Holy Cross Health will use and disclose PHI about you for payment purposes. The following are examples of how Holy Cross Health will use and/or disclose your PHI:
- To an insurance company, third party payer, third party administrator, health plan or other health care provider (or their duly authorized representatives) for payment purposes such as determining coverage, eligibility, pre-approval / authorization for treatment, billing, claims management, reimbursement audits, etc.
- To collection agencies and other subcontractors engaged in obtaining payment for care.
C. Health Care Operations:
Holy Cross Health will use and disclose your PHI for health care operation purposes. The following are examples of how Holy Cross Health will use and/or disclose your PHI:
- For case management, quality assurance, utilization, accounting, auditing, population based activities relating to improving health or reducing health care costs, education, accreditation, licensing and credentialing activities of Holy Cross Health.
- To consultants, accountants, auditors, attorneys, transcription companies, information technology providers, etc.
D. Other Uses and Disclosures:
As part of treatment, payment and health care operations, Holy Cross Health may also use your PHI for the following purposes:
- Fundraising Activities: Holy Cross Health will use and may also disclose some of your PHI to Holy Cross Health Foundation (the Foundation) for certain fundraising activities. For example, Holy Cross Health may disclose your demographic information, your treatment dates of service, treating physician information, department of service and outcomes information to the Foundation which may ask you for a monetary donation. Any fundraising communication sent to you will let you know how you can exercise your right to opt-out of receiving similar communications in the future.
- Medical Research: Holy Cross Health will use and disclose your PHI without your authorization to medical researchers who request it for approved medical research projects. Researchers are required to safeguard all PHI they receive.
- Information and Health Promotion Activities: Holy Cross Health will use and disclose some of your PHI for certain health promotion activities. For example, your name and address will be used to send you general newsletter or specific information based on your own health concerns.
E. Stricter State and Federal Laws:
Certain Maryland laws may be stricter than HIPAA in several areas. Certain federal laws also are stricter than HIPAA. Holy Cross Health will continue to abide by these stricter state and federal laws.
i. Stricter Federal Laws:
The federal laws include applicable internet privacy laws, such as the Children’s Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment.
ii. Stricter State Laws:
The Maryland law on who may release information based on a valid consent still applies. In addition, except in certain situations, a patient’s authorization to disclose medical records may not exceed one year. Maryland law also allows disclosure of PHI to state agencies for certain medical conditions such as birth defects, cancer, communicable diseases and HIV/AIDS.
F. Health Information Exchange:
Holy Cross Health shares your health records electronically with Chesapeake Regional Health Exchange (“CRISP”) which is a statewide, state-approved and internet based health information exchange for the purpose of improving the overall quality of health care services provided to you. For example, we can check lab test results recently performed by your doctor and avoid unnecessary duplicate testing. Information about your past medical history or your current medical condition and medications may be available through CRISP, as long as the other physicians or hospitals where you received care participate in CRISP. The electronic health records may include sensitive diagnoses such as HIV/AIDS, sexually transmitted diseases, genetic information, mental health, and substance abuse, etc. CRISP serves as our business associate and, in acting on our behalf, CRISP will transmit your PHI for treatment, payment and health care operation purposes. The CRISP has a duty to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your medical information.
You have the right to “opt-out” of CRISP by completing and submitting an "Opt-Out" form to CRISP by mail, fax or web-site. If you do opt-out, you health information will not be available to be searched by other providers. If you opt out, it is possible that a certain amount of your medical information may be retained by CRISP and diagnostic information could be accessed by your doctor. You may opt out by contacting CRISP by telephone, fax, e-mail, or website.
Chesapeake Regional Information System for our Patients
7160 Columbia Gateway, Suite #230
Columbia, MD 21046
Phone (877) 952-7477
Facsimile: (443) 817-9587
II. Permitted Use or Disclosure with an Opportunity for You to Agree or Object
Holy Cross Health will disclose PHI about you to a friend or family member who is involved in or paying for your medical care. You have a right to request that your PHI not be shared with some or all of your family or friends. In addition, Holy Cross Health will disclose PHI about you to an agency assisting in disaster relief efforts so that your family can be notified about your condition, status, and location.
B. Holy Cross Health – Facility Directory:
Holy Cross Health will include certain information about you in facility directory while you are a hospital patient at Holy Cross Health. This information will include your name, location in Holy Cross Health, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation. The directory information, except your religious affiliation, will be disclosed to people who ask for you by name. You have the right to request that your name not be included in Holy Cross Health's directory. If you request to opt-out of the facility directory, we cannot inform visitors of your presence, location, or general condition.
C. Spiritual Care:
Directory information, including your religious affiliation, will be given to a member of the clergy, even if they do not ask for you by name. Spiritual care providers are members of the health care team at Holy Cross Health and may be consulted upon regarding your care. You have the right to request that your name not be given to any member of the clergy.
D. Media Reports:
Holy Cross Health will release facility directory information to the media (excluding religious affiliation) if the media requests information about you using your name and after we have given you an opportunity to agree or object.
III. Use or Disclosure Requiring Your Authorization
A. Marketing: Subject to certain limited exceptions, your written authorization is required in cases where Holy Cross Health receives any direct or indirect financial benefit in exchange for making the communication to you which encourages you to purchase a product or service or for a disclosure to a third party who wants to market their products or services to you.
Holy Cross Health will obtain your written authorization to use or disclose your PHI for research purposes when required by HIPAA.
C. Psychotherapy Notes:
Most uses and disclosures of psychotherapy notes require your written authorization.
D. Sale of PHI:
Subject to certain limited exceptions, disclosures that constitute a sale of PHI require your written authorization.
E. Other Uses and Disclosures:
Any other uses or disclosures of PHI that are not described in this Notice of Privacy Practices require your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.
IV. Use or Disclosure Permitted or Required by Public Policy or Law without your Authorization
A. Law Enforcement Purposes:
Holy Cross Health will disclose your PHI for law enforcement purposes as required by law, such as identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.
B. Required by Law:
Holy Cross Health will disclose PHI about you when required by federal, state or local law. Examples include disclosures in response to a court order / subpoena, mandatory state reporting (e.g., gunshot wounds, victims of child abuse or neglect), or information necessary to comply with other laws such as workers’ compensation or similar laws. Holy Cross Health will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies.
C. Public Health Oversight or Safety:
Holy Cross Health will use and disclose PHI to avert a serious threat to the health and safety of a person or the public. Examples include disclosures of PHI to state investigators regarding quality of care or to public health agencies regarding immunizations, communicable diseases, etc. Holy Cross Health will use and disclose PHI for activities related to the quality, safety or effectiveness of FDA regulated products or activities, including collecting and reporting adverse events, tracking and facilitating in product recalls, etc.
D. Coroners, Medical Examiners, Funeral Directors:
Holy Cross Health will disclose your PHI to a coroner or medical examiner. For example, this will be necessary to identify a deceased person or to determine a cause of death. Holy Cross Health may also disclose your medical information to funeral directors as necessary to carry out their duties.
E. Organ Procurement:
Holy Cross Health will disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.
F. Specialized Government Functions:
Holy Cross Health will disclose your PHI regarding government functions such as military, national security and intelligence activities. Holy Cross Health will use or disclose PHI to the Department of Veterans Affairs to determine whether you are eligible for certain benefits.
Holy Cross Health will disclose proof of immunization to a school where the state or other similar law requires it prior to admitting a student.
V. Your Health Information Rights
You have the following individual rights concerning your PHI:
A. Right to Inspect and Copy:
Subject to certain limited exceptions, you have the right to access your PHI and to inspect and copy your PHI as long as we maintain the data.
If Holy Cross Health denies your request for access to your PHI, Holy Cross Health will notify you in writing with the reason for the denial. For example, you do not have the right to psychotherapy notes or to inspect the information which is subject to law prohibiting access. You may have the right to have this decision reviewed.
You also have the right to request your PHI in electronic format in cases where Holy Cross Health utilizes electronic health records. You may also access information via patient portal if made available by Holy Cross Health.
You will be charged a reasonable copying fee in accordance with applicable federal or state law.
B. Right to Amend:
You have the right to amend your PHI for as long as Holy Cross Health maintains the data. You must make your request for amendment of your PHI in writing to Holy Cross Health, including your reason to support the requested amendment.
However, Holy Cross Health will deny your request for amendment if:
- Holy Cross Health did not create the information;
- The information is not part of the designated record set;
- The information would not be available for your inspection (due to its condition or nature); or
- The information is accurate and complete.
If Holy Cross Health denies your request for changes in your PHI, Holy Cross Health will notify you in writing with the reason for the denial. Holy Cross Health will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that Holy Cross Health include your request for amendment and the denial any time that Holy Cross Health subsequently discloses the information that you wanted changed. Holy Cross Health may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.
C. Right to an Accounting:
You have a right to receive an accounting of the disclosures of your PHI that Holy Cross Health has made, except for the following disclosures:
- To carry out treatment, payment or health care operations;
- To you;
- To persons involved in your care;
- For national security or intelligence purposes; or
- To correctional institutions or law enforcement officials.
You must make your request for an accounting of disclosures of your PHI in writing to Holy Cross Health.
You must include the time period of the accounting, which may not be longer than 6 years. In any given 12-month period, Holy Cross Health will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting.
D. Right to Request Restrictions:
You have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or health care operations functions or to prohibit such disclosure. However, Holy Cross Health will consider your request but is not required to agree to the requested restrictions.
E. Right to Request Restrictions to a Health Plan:
You have the right to request a restriction on disclosure of your PHI to a health plan (for purposes of payment or health care operations) in cases where you paid out of pocket, in full, for the items received or services rendered.
F. Right to Confidential Communications:
You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that Holy Cross Health only contact you at work or by mail.
G. Right to Receive a Copy of this Notice:
You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.
VI. Breach of Unsecured PHI
If a breach of unsecured PHI affecting you occurs, Holy Cross Health is required to notify you of the breach.
VII. Sharing and Joint Use of Your Health Information
In the course of providing care to you and in furtherance of Holy Cross Health’s mission to improve the health of the community, Holy Cross Health will share your PHI with other organizations as described below who have agreed to abide by the terms described below:
A. Medical Staff. The medical staff and Holy Cross Health participate together in an organized health care arrangement to deliver health care to you. Both Holy Cross Health and medical staff have agreed to abide by the terms of this Notice with respect to PHI created or received as part of delivery of health care to you by Holy Cross Health. Physicians and allied health care professionals who are members of Holy Cross Health’s medical staff will have access to and use your PHI for treatment, payment and health care operations purposes related to your care within Holy Cross Health. Holy Cross Health will disclose your PHI to the medical staff and allied health professionals for treatment, payment and health care operations.
B. Membership in CHE Trinity Health. Holy Cross Health and members of CHE Trinity Health participate together in an organized health care arrangement for utilization review and quality assessment activities. We have agreed to abide by the terms of this Notice with respect to PHI created or received as part of utilization review and quality assessment activities of CHE Trinity Health and its members. Members of CHE Trinity Health will abide by the terms of their own Notice of Privacy Practices in using your PHI for treatment, payment or health care operations. As a part of CHE Trinity Health, a national Catholic health care system, Holy Cross Health and other hospitals, nursing homes, and health care providers in CHE Trinity Health share your PHI for utilization review and quality assessment activities of CHE Trinity Health, the parent company, and its members. Members of CHE Trinity Health also use your PHI for your treatment, payment to Holy Cross Health and/or for the health care operations permitted by HIPAA with respect to our mutual patients.
Please go to CHE Trinity Health’s websites for a listing of member organizations at http://www.trinity-health.org/ and http://www.che.org/. Or, alternatively, you can call Holy Cross Health’s Privacy Official to request the same.
C. Business Associates. Holy Cross Health will share your PHI with business associates and their Subcontractors contracted to perform business functions on behalf of Holy Cross Health, including CHE Trinity Health which performs certain business functions for Holy Cross Health.
VIII. Changes to this Notice.
Holy Cross Health will abide by the terms of the Notice currently in effect. Holy Cross Health reserves the right to make material changes to the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. Holy Cross Health will distribute / provide you with a revised Notice at your first visit following the revision of the Notice in cases where it makes a material change in the Notice. You can also ask Holy Cross Health for a current copy of the Notice at any time.
If you believe your privacy rights have been violated, you may file a complaint with Holy Cross Health’s Privacy Official or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing directly to Holy Cross Health’s Privacy Official. Holy Cross Health assures you that there will be no retaliation for filing a complaint. You will not be retaliated against for filing any complaint.
X. Privacy Official - Questions / Concerns / Additional Information.
If you have any questions, concerns, or want further information regarding the issues covered by this Notice of Privacy Practice or seek additional information regarding Holy Cross Health’s privacy policies and procedures, please contact Holy Cross Health’s Privacy Official: at 1500 Forest Glen Road, Silver Spring, MD 20910 or 301-754-7870.