Effective April 14, 2003

Notice of Privacy Practices

THIS NOTICE DESCRIBES THE PRIVACY PRACTICES OF EPISCOPAL HEALTH SERVICES INC. AND THE MEDICAL STAFF OF OUR FACILITIES. 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.

OUR PRIVACY OBLIGATIONS

We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI and to have you sign a written acknowledgment that you received this Notice. When we use or disclose your PHI, we are required to abide by the terms of this Notice.

WHO WILL FOLLOW THIS NOTICE:

This notice describes our institutions’ practices and that of:

   ØAny health care professional authorized to enter information into your medical record.

  ØAll affiliates of EHS. “Affiliates” means, with respect to EHS, all entities now or hereafter owned or operated by, under common control or management with, controlling or        controlled by, or otherwise affiliated with EHS, including, without limitation, St. John’s Episcopal Hospital, South Shore, Bishop Charles Waldo MacLean Nursing Home and        Bishop Henry B. Hucles Episcopal Nursing Home.

  ØAny member of a volunteer group we allow to help you while you are a patient/resident at an EHS facility.

  ØAll employees, staff, affiliated/contract staff, students and other EHS personnel.

Intent of this Notice:

This notice will tell you about the ways in which we may use and disclose health care information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of this information.

HOW WE MAY USE AND DISCLOSE HEALTH CARE INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health care 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 your PHI or share it with doctors, nurses or others personnel within EHS in order to diagnoses and treat your condition. In addition, the Hospital personnel may provide PHI to other healthcare providers information in order for them to provide you with care and treatment.

For Payment. We may use your PHI or share it with others so that we may obtain payment for your health care services.

For Health Care Operations. We may use your PHI or share it with others in order to conduct our business operations. For example, we may use your PHI to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide to you.

Appointment Reminders. We may use and disclose health care information to contact you as a reminder that you have an appointment for treatment or care at EHS.

Treatment Alternatives. We may use and disclose health care 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 health care information to tell you about health-related benefits or services that may be of interest to you.

Fundraising Activities. We may disclose to our fundraising staff demographic information about you (e.g., your name, address and phone number) and dates on which we provided health care to you, without your written authorization. If you do not want EHS to release this information about you for fundraising efforts, you must notify the Development Department of St. John’s Episcopal Hospital at 718-869-7750.

Hospital/Nursing Home Directories: We may include certain limited information about you in the St. John’s Episcopal Hospital patient directory or in the Nursing Homes facility directories while you are a patient at the hospital or a resident in one of our nursing homes. This information may include your name, location in the hospital or nursing home and your religious affiliation. The information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital or nursing homes. If you don’t wish to be included on our patient/resident list, please notify the admitting office at the Hospital or the Nursing Director at either nursing home.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member that you indicate is involved in your care or the payment for your care unless you object in whole or in part. Information is not released routinely about patients on the Psychiatric Units or Chemical Dependency Unit. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Business Associates. We may disclose your PHI to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. If we do disclose your PHI to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your PHI.

Research. In most cases, we will ask for your written authorization before using your PHI or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your PHI without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly.

As Required By Law. We may use or disclose your PHI if we are required by law to do so. We also will notify you of these uses and disclosures if notice is required by law.

To Avert a Serious Threat to Health or Safety. We may use and disclose health care information 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 help prevent the threat.

SPECIAL SITUATIONS:

Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ, eye or tissue procurement/ 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 health care information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation: We may disclose your PHI for workers’ compensation or similar programs that provide benefits for work-related injuries. Public Health Risks: We may disclose health care information about you for public health activities. These activities generally include the following: (1) To prevent or control disease, injury or disability; (2) To report births and deaths; (3) To report child or elder abuse; (4) To report reactions to medications or problems with products; (5) to regulatory agencies as required by State or federal law; (6) To notify people of recalls of products they may be using; (7) To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Health Oversight Activities: We may disclose health care information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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. To 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. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health care information about you in response to a court or administrative order. We may also disclose health care information about you to comply with a subpoena, court order, or other lawful process by someone else involved in the dispute, provided that the request meets all of the legal requirements and is valid. Law Enforcement: We may release health care information if asked to do so by a law enforcement official: (1) In response to a court order, subpoena, warrant, summons or similar process; (2) To identify or locate a suspect, fugitive, material witness, or missing person; (3) About a victim or the suspected victim of a crime. (4) About a death we believe may be the result of criminal conduct; About criminal conduct at the hospital; and (5) In certain 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 health care 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 patients of the hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities: We may release health care information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others: We may disclose health care information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Patients under Custody of Law Enforcement: If you are under the custody of a law enforcement official we may release health care information about you to the law enforcement official. This release would be necessary for the institution to provide you with health care and/or to protect your health and safety or the health and safety of others. 

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of health care information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose health care information about you, you may revoke it, in writing, at any time. If you revoke it, we will no longer use or disclose health care information about you for the reasons covered by your written authorization, unless required by law. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

Right to Inspect and Copy. You have the right to inspect and have copied information that is considered part of your medical, dental and billing records that may be used to make decisions about your care. To inspect and/or have copied health care information about you, you must submit your request in writing. For residents at either Nursing Home please submit this written request to the facilities Director of Nursing. We will respond to your request to inspect your record within 24 hours and copies of your record will general take two working days. For patients of the Hospital please submit this request to the Director of the Medical Records Department. We will respond to your request to inspect your record within 10 days. Ordinarily we will respond to a request for a copy of your record within 30 days if the information is located at our facility and within 60 days if it is located off-site at another facility. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We will respond within 30 days of receiving your written request. We may deny your request to inspect and copy in certain very limited circumstances. In certain circumstances, if you are denied access to your information, you may request that the denial be reviewed. Another licensed health care professional chosen by the EHS will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Risk Management Department and submit the completed form to the Director of Risk Management/Corporate Compliance. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. For either of our Nursing Homes, please contact the Director of Nursing of that facility. Your request must be made in writing with a reason to support the request. Ordinarily, we will respond within 60 days of receiving your written request. If addition time is needed we will notify you. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement. We will include this statement in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services.

Right to an Accounting of the Disclosures We Have Made About You. You have a right to request an “accounting of disclosures” which identifies certain other persons or organizations to whom we have released your PHI in accordance with applicable law and the protections afforded in this Notice of Privacy Practices. An accounting of disclosures does not include the following: Disclosures we made to you or your personal representative; Disclosures we made pursuant to your written authorization; Disclosures we made for treatment, payment or business operations; Disclosures made from the patient directory; Disclosures made to your friends and family involved in your care or payment for your care; Disclosures that were incidental to permissible uses and disclosures of your PHI Disclosures for purposes of research, public health or our business operations of limited portions of your PHI that do not directly identify you; Disclosures made to federal officials for national security and intelligence activities; Disclosures about inmates to correctional institutions or law enforcement officers; Disclosures made before April 14, 2003.

To request this list of disclosures, you must submit your request in writing. For patients of our Hospital please contact the Risk Management/Corporate Compliance Office. For either of our Nursing Homes, please contact the Director of Nursing at either facility. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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 costs involved and you may alter your request before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health care 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 health care 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. We are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions regarding payment, you must make your restriction request known at the time of your registration. Any other restrictions must be in writing to the following: For patients of our Hospital please contact the Risk Management/Corporate Compliance Office. For either of our Nursing Home, please contact the Director of Nursing at either facility. 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. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request at the time of registration or by calling the Admitting Office at the Hospital or Nursing Homes. We will not ask you the reason for your request. 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 may obtain a paper copy of this notice at the Office of Patient Relations or at any location where you receive care. You may ask us to give you a copy of this notice at any time or download this notice at our website, /. We will ask that you acknowledge receipt of this notice in writing.

CHANGES TO THIS NOTICE. We reserve the right to change the terms of this notice and We reserve the right to make the revised or changed notice effective for information we already have about you as well as any information we receive in the future all PHI we maintain. We will post copies of the current notice in all locations where you may receive care. The effective date of the notice is contained on the first page. 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.

COMPLAINTS. You will not be penalized for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the EHS or with the Secretary of the Federal Department of Health and Human Services (DHHS). To file a complaint with the EHS, contact the Director of Risk Management/Corporate Compliance at (718) 869-7665. All complaints must be submitted in writing.

Please direct questions about this notice to the Office of the Risk Management/Corporate Compliance at (718)-869-7665.

To file a complaint with the DHHS, you must file in writing (electronic or paper), within 180 days of when you knew, or should have known of the problem. Send your complaint to

DHHS Regional Manager, Office for Civil Rights
U.S. Department of Health and Human Services Government Center
J.F. Kennedy Federal Building - Room 1875
Boston, Massachusetts 02203
Voice phone (617) 565-1340
FAX (617) 565-3809
TDD (617) 565-1343