Kennedy Health System

Who Will Follow This Notice

• Any health care professional authorized to enter information into your medical record while working at any Kennedy site,
• All departments and units of the health system,
• Any member of a volunteer group we allow to help you while you are a patient in the health system, and
• All employees, staff and other health system personnel.

We Have A Legal Duty To Safeguard Your Protected Health Information (PHI)

• Place limitations on the types of uses and disclosures health care providers and others may make of your PHI.
• To follow State and other regulations that afford more protections of your PHI or provide additional patient rights that exceed those under HIPAA. These include but are not limited to HIV/AIDS, venereal disease, genetic testing, drug and alcohol as well as mental health facility records and minors who independently consent to treatment in accordance with State law.
• In these and all other applicable cases, Kennedy will abide by the most stringent of the regulations as they pertain to PHI, including obtaining our prior written consent, as required, before any such information is disclosed to a third party. These restrictions also apply to the sharing of any such special categories of information through the KennedyConnect Health Information Exchange (HIE).

How We May Use Or Disclose Your Protected Health Information

Health information about You for Treatment, Payment and our Healthcare Operations may be used or disclosed without your written authorization in the following circumstances:

• For Treatment – We may use and disclose your health information to a physician or other healthcare providers to provide you with medical treatment and services. For example various departments may share PHI about you in order to coordinate items and services that you require, such as medications, laboratory work, medical imaging studies and/or home health care for needed medical services after your discharge.

In addition, unless you opt-out, any authorized health care provider who agrees to participate in KennedyConnect HIE can also electronically access and use your PHI if needed to provide treatment to you. For instance, if you receive a blood test from one provider in the KennedyConnect HIE network but then are treated by a different provider within our HIE, both of your testing providers can share your test results electronically through the secure KennedyConnect HIE network, as long as they are otherwise authorized to do so. If you opt-out of the KennedyConnect HIE, your PHI will continued to be accessed and released electronically or otherwise as needed to provide treatment to you, but will not be made available for such purpose through the KennedyConnect HIE.

• For Payment – We may use and disclose your PHI in order to bill and collect payment for treatment and services provided to you. For example, in order for Kennedy to receive payment from your insurance provider, we will need to tell your insurance company about services that were provided to you
• For Health Care Operations – We may use and disclose PHI about you for hospital and health care system operations. Some of the ways in which we use your health information include monitoring the quality of care that is provided to our patients; checking our compliance with laws and other legal obligations; education and training of our staff, including physicians in training; business planning and development; business management and administration; in addition to evaluating our processes and procedures to find ways to improve our services to the community.
• To Our Business Associates - We may disclose your health information to organizations or individuals who carry out certain key activities or processes for Kennedy, such as billing, transcription services and medical equipment. Before we disclose you health information under these circumstances, we will require the “business associate” to which we make a disclosure to have a written contract in place that restricts the ability of the business associate to use or disclose your PHI in accordance with HIPAA regulations.
• Appointment Reminders– We may use and disclose your health information to provide you with appointment reminders (such as voicemail message, postcards and letters) at Kennedy.
• Treatment Alternatives and Health related benefits or services - We may use and disclose PHI to provide you with information about treatment options or alternatives or to recommend health related benefits or services provided by Kennedy that may be of interest to you.
• Development and Fundraising activities – We may contact you to provide you with information regarding Kennedy Health System sponsored activities, such as fundraising events and programs. For this purpose we will only use contact information such as your name, address and phone number as well as the dates you received treatment or services at a Kennedy facility. You have no obligation to respond to these communications and you have the option to opt-out of receiving such communications in the future. If you do not wish to be contacted please notify the Chief Privacy officer in writing at the address listed below in this document.
• Health Plan – We may disclose your PHI to the sponsor of your health plan.
• Change of Ownership – In the event that Kennedy is sold or merged with another organization, your PHI/record will become the property of the new owner.

Uses and Disclosures that Require You to Have the Opportunity to Agree or Object

• To Notify and/or Communicate with your family – Unless you inform us of your objection in writing, we will use or disclose your PHI in order to notify your family or to assist in notifying your family, your personal representative or another person responsible for your care about your location, your condition or of your death. We may discuss your health care with your family and to the extent that they are involved in your care with your friends. If you are unable to or unavailable to agree or object to our discussing these matters with your family and/or friends, our health professionals will use their judgment as to whether any communication with your family or others are necessary and/or appropriate.
• Facility Directories – With the exception of patients being treated on our Behavioral Health units; we may include your name, location in the hospital, your general condition and your religious affiliation in the hospital directory while you are a patient in the hospital. Aside from religious affiliation, the directory information may also be released to people who ask for you by name except if you are a Behavioral Health Services patient. Your religious affiliation may be given to a member of the clergy, such as a priest, minister, or rabbi, even if the clergy member did not ask for you by name. You may restrict or prohibit your PHI being placed in the directory. The opportunity to object may be obtained retroactively in emergency situations.
• Individuals involved in your care or payment for your care – Unless you object in whole or in part, we may release PHI about you to a family member, friend, or other person who is involved in your medical care. We may also give information to someone who helps pay for your care. The opportunity to object may be obtained retroactively in emergency situations.
• Disaster relief efforts - We may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status or location.
• Persons acting on behalf of you – If you are not present or able to agree or to object to a disclosure, we will use professional judgment and experience to determine whether it is in your best interest to allow another person to act on your behalf to pick up filled prescriptions, medical supplies, medical imaging studies or other similar forms of your PHI.
• All Other Uses and Disclosures Require Your Prior Written Authorization – In any other situation not described the sections 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 authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization. We are unable to take back any disclosures of your information that we have already made with your authorization.

Disclosures That Do Not Require Your Authorization

• Information provided to you.
• As Required by Law – PHI will be used and disclosed to the extent that such use or disclosure is required by law. Examples of such requirements are: communicable diseases reporting, incidence of cancer, burns, seizures, gun shots, abuse, neglect, organ donation, product recalls, births, birth defects, death or when ordered in a judicial or administrative proceeding.
• For Public Health Activities – PHI will be provided to local, state or federal public health authorities, as authorized or required by law to prevent or control disease, injury, or disability; to report child abuse or neglect; report to the Food and Drug Administration problems with products and reactions to medications and report disease or infection exposure.
• For Health Oversight Activities – We may disclose your health information to governmental, licensing, auditing and accrediting agencies for activities authorized by law.
• Lawsuits and Other Legal Actions – In general we may disclose your health information in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other lawful action. However, we will attempt to ensure that you have been made aware of this use or disclosure of your PHI prior to its release.
• To Law Enforcement Personnel – PHI will be used and disclosed to law enforcement officials to identify or locate a suspect, fugitive, material witness or missing person, or, in some cases, to comply with a court order or subpoena and for other law enforcement purposes.
• To Correctional Institutions – If you are an inmate or under the custody of a law enforcement institution or law enforcement official, we may disclose information about you to the institution.
• For Purposes of Organ and Tissue Donation – We may release PHI to organizations that handle organ or tissue procurement, transplantation or banking as necessary to facilitate organ or tissue donation and transplantation.
• To Coroners, Medical Examiners and Funeral Directors – PHI may be disclosed for purposes of communicating with coroners, medical examiners, and funeral directors.
• To Aid Specific Governmental Functions – We may disclose PHI of military personnel and veterans, as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority. We may disclose PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities as authorized by law. We may also disclose PHI about you to authorize federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations.
• For Workers’ Compensation – We may release PHI about your for workers’ compensation or similar programs as required by workers’ compensation law.
• For Research – Under certain circumstances, we may use and disclose PHI about you for research purposes. Although we will generally only use your health information in connection with research projects. Before we use or disclose PHI for research, the project will have been approved through a research approval process. We may, however, disclose PHI about you to medical staff or Kennedy associates preparing to conduct a research project, provided that the PHI they review is not removed from Kennedy. In addition, some research will be conducted using a limited data set of PHI that excludes patient names and other identifying information that we maintain for research and quality improvement. We will contact you to obtain your specific permission if the researcher will be disclosing information that could be used to identify you or if the researcher will be involved in your care at Kennedy.
• 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. Any disclosure, however, would only be to someone able to help prevent or lessen the threat.
• Health Information Exchange – Kennedy and other healthcare providers participate in a Health Information Exchange which allows patient information to be shared electronically. The HIE allows for immediate electronic access to your participating health care provider(s) and health plan’s pertinent medical information necessary for treatment, payment and operations. If you have not opted-out of the HIE, your information will be available through the HIE to participating health care providers and health plans in accordance with the Notice of Privacy Practices and the law. If you opt-out of the HIE, your personal health information will continue to be used in accordance with this Notice and the law, but will not be made available through the HIE.

Your Rights Regarding Health Information About You

• Right to Request Restrictions – You have the right to request restrictions on the uses and disclosures of your PHI. This means that you may ask us not to use or disclose any part of your PHI for treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care, or for notification purposes as described in this Joint Notice. Any such requests for restrictions must be in writing, be addressed to the Privacy Officer and state the specific restriction requested and to whom you want the restriction to apply. However, we are not required to comply with your request unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains exclusively to a health care item or service for which you have paid us “out of pocket” in full.

With regard to KennedyConnect HIE only, if you do not wish to allow otherwise authorized doctors, nurses and other clinicians involved in your care to electronically share your PHI with one another through the KennedyConnect HIE as set forth in this Joint Notice, you can complete, sign and submit the KennedyConnect HIE Opt-Out form to your provide, or by fax or mail as instructed on that form, and we will honor any Opt-Out selection you make. The KennedyConnect HIE Opt-Out form can be obtained directly from any KennedyConnect HIE participating provider, or you can download the form from www.kennedyhealth.org or by calling (856)661-5227. If you opt-out of the KennedyConnect HIE, your PHI will continue to be accessed and released, electronically or otherwise, as needed to provide treatment to you, but will not be made available for such purposes through the KennedyConnect HIE.

• Right to Choose How We Sent PHI to You – You have the right to request your PHI be received by you through confidential means. However, we may condition this accommodation by asking you for information as to how payment will be handled or a specification of an alternative address or other method of contact such e-mail instead of regular mail delivery. We will not ask for an explanation from you regarding this request. Your request must be sent in writing to the attention of the Privacy Officer and must specify the alternate means of communication as well as location.
• Right to Inspect and Obtain a Copy– With certain exceptions, you have the right to inspect and/or receive a copy of your health information. This right does not include a right to psychotherapy notes. To inspect and/or receive a copy of your health information, you must submit your request in writing to the Director of Health Information Management. If you request a copy of the information, we may charge a fee for the costs of copying, mailing and or other supplies associated with your request. We will respond to you within 30 days of receiving your written request.
  • We may deny your request in certain circumstances. If we do, we will tell you in writing our reasons for the denial and explain your rights to have the denial reviewed. If your request a review of the denial another licensed health care professional chosen by Kennedy will review your request and the denial. The person conducting the review will not be the person who denied your request. We will abide by the outcome of this review.
• Right to Request an Amendment – You have the right to request that we amend the PHI contained in your Designated Record Set if you believe it is incorrect or incomplete. You must provide the completed Request for Correction/Amendment to Medical Records containing an explanation for this request in writing to the Chief Privacy Officer. A copy of the Request for Correction/Amendment document is available from our Medical Records Department. We will respond within 60 days of receiving your request. If additional time is required to complete your request we will notify you by mail of our need for a 30 day extension. However, we are not required to make any such amendments. If we deny a request, we will provide you with a copy of any such rebuttal. All of these documents will be placed in the appropriate part of your Designated Record Set. If you are requesting that we amend your records because you believe that you are a victim of medical identify theft, we will use reasonable efforts to assist you in making corrections to your record which are determined to be appropriate under the circumstances.
• Right to an Accounting of Disclosures – You have a right to receive an accounting of disclosures of you PHI made by us, with the exception of disclosures: made prior to April 14, 2003; authorized by you; made for treatment, payment or health care operations (unless such disclosures were made through an EHR, in which case an additional accounting may be provided to you in accordance with applicable law); provided in response to an Authorization; made in order to notify and communicate with family; for certain government functions; and/or disclosures provided to you. The right to receive an accounting is subject to exceptions, restrictions and limitations.
• Right to a Paper Copy of this Notice – You have the right to a paper copy of this notice, even if you have agreed to accept a copy of this Joint Notice either via e-mail or other electronic means.

Our Duties to You

Complaints and Further Information

If you believe that your privacy rights have been violated, you may file a complaint with Kennedy or the Secretary of the United States Department of Health and Human Services. To file a complaint with Kennedy, or to receive further information on our privacy practices or the content of this Notice, contact the Chief Privacy Officer: Kennedy Center at Voorhees, 1099 White Horse Road, Voorhees, NJ 08043-4405. You may also call the Privacy Hotline at (856) 346-7500 or toll free at (855) 235-1959. Alternately you may send a written complaint to the Secretary of the Department of Health and Human Services at the following address: The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Washington, D.C. 20201. All complaints must be in writing and we promise not to retaliate against you.

Confidentiality and Privacy Practices Translations

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HIPPA and Privacy Practices in English.