Notice of Privacy Practices

Effective Date: April 1, 2021 (Previous Versions Effective April 15, 2003, September 23, 2013, and May
31, 2019).

This Notice of Privacy Practices (“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.

This Notice is available on our website at www.southcoast.org and at all Southcoast locations.

If you have any questions about this notice, please contact Southcoast’s Privacy Officer at 508-973-5040.

Our Pledge Regarding Medical Information

We understand that information about you and your health is personal. We are committed to protecting medical information about you. Throughout this Notice, when we refer to “Southcoast,” “we,” “us” or “our,” we are referring to Southcoast Health System, Inc., which includes the following entities: Southcoast Hospitals Group, Inc. (which consists of Charlton Memorial Hospital, St. Luke’s Hospital, and Tobey Hospital (collectively, the “Hospital”)), as well as Southcoast Visiting Nurse Association, Inc., and Southcoast Physicians Group, Inc. We create a record of the care and services you receive at Southcoast. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by Southcoast.

This Notice will tell you about the ways in which we may use and disclose medical information about you. This Notice also describes your rights and certain obligations regarding the use and disclosure of your medical information.

It is our responsibility and we are required by law to:

maintain the privacy and security of your medical information;
give you this Notice of our legal duties and privacy practices with respect to your medical information;
follow the terms of this Notice; and
notify you if there is a breach of your medical information.

This Notice describes our practices and applies to:

any health care professional authorized to enter information into our electronic health record (“EHR”), including the doctors on the Hospital’s medical staff;
all departments and units of Southcoast;
any member of a volunteer group we allow to help you while you are in our Hospital or being treated at Southcoast;
any trainee or student who we allow to help you while you are in our Hospital or being treated at Southcoast; and
outside entities under contract with Southcoast to provide certain services involving the use of medical information (known as “business associates” of Southcoast).

This Notice will explain in detail:

How we may use and disclose medical information about you;
Special situations in which we may use and disclose medical information about you;
Your rights regarding medical information about you;
Changes to this Notice;
Southcoast Hospitals Group’s Record Retention Policy; and
Complaints.

1. How we may use and disclose medical information about you

Southcoast uses several electronic systems to use and maintain an electronic health record (“EHR”). Information in our EHR may be shared with other health care providers, including other providers using the same electronic systems for purposes permitted under this Notice. The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose medical information will fall within one of the categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at Southcoast. Different departments of the Southcoast entities also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside of Southcoast, such as other health care providers involved in your care, and family members or others that are involved in your care.

Example: A doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes so that we can arrange for appropriate meals.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at Southcoast may be billed to (and payment may be collected from) an insurance company, a third party, or you. We may also share your medical information with doctors, nurses, technicians and other health care personnel who are involved in your treatment at our facilities as necessary for payment activities related to their joint provision of health care, including sharing your information with third party service providers for billing, payment and collections purposes. We may use contact information provided by you to contact you directly or via a service provider, including via text, phone call, or email. By providing your contact information you consent to Southcoast using and disclosing your contact information for payment purposes in accordance with this Notice and applicable law, but you can always change your communication preferences.

Example: We may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose medical information about you to help run our facilities and make sure that all our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Example: We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many of our patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also combine the medical information we have with medical information from other providers for the purposes of comparing how we are doing and seeing where we can make improvements in the care and services we offer.

Research. We may use your medical information for research purposes when an institutional review board or privacy board has approved the research after it has reviewed the research proposal and established protocols to ensure the privacy of your medical information.

Fundraising Activities. We may use certain medical information about you to contact you in an effort to raise money for our organization. We may disclose such medical information to an affiliated foundation so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number, as well as limited information about your treatment, including the dates you received treatment or services from us. If you do not want us to contact you for fundraising efforts, you must notify the Philanthropy Department at Southcoast Hospitals Group, 141 Page Street, New Bedford, MA 02740 in writing or call 1-800-925-9450. If we send you a fundraising communication, we will also give you an opportunity to opt out of receiving future fundraising communications.

Example: We may use your medical information to ask you for donations to support the Hospital. For example, if you are a cardiology patient, we may send you a letter to support the Southcoast cardiology program.

Hospital Directory. We may include certain limited information about you in the Hospital’s directory while you are a patient at our Hospital, unless you object. This information may include your name, location in the Hospital, your general condition (e.g., Critical, Serious, Fair, Good) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. This is so your family, friends and clergy can visit you in the Hospital and generally know how you are doing. 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. Except in an emergency, you may limit or prohibit any of the previously mentioned uses or disclosures of your medical information in connection with the Hospital’s directory. In an emergency, we may include the information listed above in our directory if consistent with your prior expressed preference, and we determine it is in your best interest. We will inform you and give you an opportunity to object as soon as practicable thereafter.

Individuals Involved in Your Care or Payment for Your Care.

We may release medical information about you to a friend or family member or other relative who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in the Hospital. Prior to sharing your information, if we are not able to reasonably infer from the circumstances that you would not object to sharing information with these individuals, we will obtain your agreement or give you an opportunity to object to such sharing if you are present. If you are not present or incapacitated, or in an emergency, we may exercise professional judgment to determine whether it is in your best interests to disclose information to a friend or family member that is directly relevant to that person’s involvement in your treatment or payment for your treatment. 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.

To Avert a Serious Threat to Health or Safety.

We may use and disclose medical information about you when necessary to prevent or lessen a serious threat to your health and safety or the health and safety of the public or another person.

Within Southcoast. Your medical information may be used by any Southcoast department or Hospital Medical Staff member as necessary for treatment, payment and health care operations purposes so long as only the minimum amount of information necessary is used by Southcoast for the purposes of payment and health care operations.

Business Associates. There may be some services furnished by outside entities under contract with Southcoast to provide certain services involving the use of medical information (known as “business associates”), such as a billing service, transcription company or legal or accounting consultants. We may disclose your medical information to our business associates so that they can perform the job we have contracted with them to do. To protect your medical information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information and report any breaches of medical information to us.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment at Southcoast, including via text, phone call, or email. By providing your contact information you consent to Southcoast using and disclosing your contact information for appointment reminders in accordance with this Notice and applicable law, but you can always change your communication preferences. If we are unable to speak with you directly, in certain situations we may leave you messages (via voice or electronic mail) containing limited information about your treatment where we determine it is in your best interests and not contrary to your prior expressed preferences for communication.

Treatment Alternatives and Other Health-Related Benefits and Services.

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives and to tell you about health related benefits, services, or medical education classes that may be of interest to you.

2. Special situations in which we may use and disclose medical information about you

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health. We may disclose your medical information for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, disability, or for oversight activities.

Health Oversight Activities. We may disclose medical information to a health oversight agency for oversight activities authorized by law. These oversight activities include, for example, audits, investigations, accreditation, inspections, licensure, and disciplinary action.

Required by Law or for Law Enforcement or Legal Purposes. We may use and disclose your medical information as required by law, for law enforcement purposes, or as part of legal proceedings. For example, we may disclose information for the following purposes:

for judicial and administrative proceedings under legal authority, e.g., to respond to a lawful administrative order or subpoena;
to report information related to victims of abuse, neglect or domestic violence; or
to assist law enforcement officials in their law enforcement duties.

Coroners, Medical Examiners and Funeral Directors. We may release medical 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 to funeral directors as necessary to carry out their duties.

Government Functions. Your medical information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

We will not share your medical information unless you give us written permission in the following cases (except as indicated):

• Psychotherapy Notes. We must obtain your authorization for most uses or disclosures of your psychotherapy notes. Under certain circumstances, your authorization is not required. For example, we may use or disclose your psychotherapy notes to carry out specific treatment, payment, or health care operations. In addition, we may use or disclose your psychotherapy notes for specific health oversight activities and when required by law.

• Marketing. We must obtain your authorization for any use or disclosure of your medical information for marketing purposes, except face-to-face communications between us or when we provide you with a promotional gift of nominal value.

• Sale of Medical Information. We must obtain your authorization for any disclosure of your medical information that is a sale of medical information.

Other Uses. Uses and disclosures of your medical information for purposes not described in this Notice may only be made with your permission using a written authorization or as permitted under applicable State and Federal law. If you agree to provide a written authorization for the use or disclosure of your medical information, you can revoke that authorization at any time, except to the extent that we have already relied upon the authorization prior to its revocation.

Additionally, certain types of medical information receive heightened confidentiality protections under Federal or State law, and therefore may not be used or disclosed – even for treatment, payment, or health care operations purposes – without a written authorization. For example, HIV test results, records of substance use disorder treatment at a specialized program (as discussed below), psychotherapy notes, and certain genetic test results may be subject to heightened confidentiality protections under the law, and you may be required to provide a specific written authorization prior to any use or disclosure of these types of medical information. We generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a specific authorization or a court orders the disclosure.

Mental Health Information. We will only disclose mental health information pursuant to an authorization, court order or as otherwise required by law. For example, communications between you and a psychologist, psychiatrist, social worker and certain therapists and counselors may be privileged and confidential under State and/or Federal law.

Substance Use Disorder Diagnosis and Treatment Information. If you are treated in a specialized substance use disorder program (including by a specialized substance use disorder provider at one of our facilities), any records of that treatment or pertaining to your substance use disorder are subject to heightened protection under Federal and State law and regulations. We may not disclose that you have been diagnosed with or received treatment for a substance use disorder or any information regarding your substance use disorder treatment, unless:

You consent in writing;
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation, or to a qualified service organization or an entity with administrative control over a specialized substance use disorder program covered under these Federal laws and regulations.

Violation of Federal laws and regulations governing the confidentiality of substance use disorder treatment records is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the substance use disorder program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations also allow information about suspected child abuse or neglect to be reported under State law to appropriate State or local authorities. The Federal law and regulations governing substance use disorder treatment records can be found at 42 U.S.C. § 290dd-2 and 42 C.F.R. Part 2.

HIV related Information. We may use or disclose HIV related medical information as permitted by applicable federal and State law.

Minors. We will comply with Federal and State law when using or disclosing medical information of minors. For example, if you are a minor and are permitted by law to consent to receipt of health care treatment (e.g., related to HIV/AIDS, venereal disease, abortion, outpatient mental health treatment or alcohol/drug dependence), and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the uses and disclosures of your medical information about that treatment.

3. Your rights regarding medical information about you

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and obtain a copy of your medical information in an electronic or paper format. You must submit your request in writing to the appropriate contact listed on the last page of this Notice via mail, e-mail or fax, and we will provide a copy or summary of your medical information usually within 30 days of your request. If you request a copy of the information, we may charge a reasonable fee for the cost of copying, mailing, or other supplies associated with your request, except where the record is requested for purposes of supporting a claim or appeal under the Social Security Act or any financial needs-based benefit program, in which case no fee will be charged. If we maintain your medical information in an EHR, you have the right to obtain a copy of your information in electronic format and we will not charge you more than our labor costs of responding to your request. We may deny your request to inspect and copy in certain very limited circumstances, and you may be permitted to appeal such a denial.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment by submitting a written request that provides your reason for requesting the amendment to the appropriate contact listed on the last page of this Notice. We may deny your request for amendment if the information is not maintained by us, or we determine that your record is accurate, in which case we will notify you of our decision within 60 days. You may submit a written statement of disagreement if we decide not to amend your record.

Right to an Accounting of Disclosures. With some exceptions, you have the right to receive an accounting of certain disclosures of your medical information during the preceding six years. An accounting may not include certain disclosures of your medical information made by Southcoast, for example certain disclosures for treatment, payment or health care operations purposes, disclosures made with your written permission, disclosures to individuals involved in your care, or disclosures to communicate with you about your care. A reasonable fee may be charged for the request, if you request more than one accounting per year.

Right to Request Restrictions. You have the right to request certain restrictions or limitations on the medical 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 medical 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 will consider your request and work to accommodate it when possible. We are not required to agree to your request, provided that if your request is with respect to restricting disclosure of your medical information to a health plan for purposes of payment or health care operations and the information pertains solely to a health care item or service that you have paid for out of pocket and in full, we will agree unless required otherwise by law. To request restrictions, you must make your request in writing to the appropriate contact listed on the last page of this Notice.

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 your work address or by mail. To request confidential communications, you must make your request in writing to the appropriate contact listed on the last page of this Notice. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice. You may receive a paper copy of this Notice from us upon request, even if you have agreed to receive this Notice electronically.

Right to a Personal Representative. You may designate an individual (e.g., a health care agent) to exercise rights on your behalf concerning uses and disclosures of your medical information, or one may be designated by a court (e.g., a legal guardian) or by law (e.g., a parent if you are a minor). We may take steps to make sure the person has authority to act on your behalf as your personal representative, and we may not treat the person as your personal representative in certain circumstances.

4. Changes to This Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facilities. The Notice will contain on the first page, at the top, the effective date. We will promptly revise and distribute this Notice whenever there is a material change.

5. Southcoast Hospitals Group’s Record Retention Policy

In accordance with Hospital policy regarding record retention and State law, including without limitation M.G.L. c. 111 § 70, the Hospital will retain your medical records for at least 20 years after your discharge or final treatment from the Hospital.

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with Southcoast’s Privacy Officer at 508-973-5040 or with the Secretary of the Department of Health and Human Services. You will not be retaliated against or penalized for filing a complaint.

Southcoast Contacts

Privacy Officer
Southcoast Health System
101 Page Street
New Bedford, MA 02740
508-973-5040

Director of Medical Records
Southcoast Hospitals Group (Charlton Memorial,
St. Luke’s and Tobey Hospitals)
101 Page Street
New Bedford, MA 02740
508-973-3700

Southcoast Visiting Nurse Association, Inc.
200 Mill Road
Fairhaven, MA 02719
508-973-3200 or 800-698-6877

Physician Offices:
Southcoast Physicians Group, Inc.
200 Mill Road, Suite 180
Fairhaven, Ma 02719
508-973-2750

Contact Information for Requests for Patient Medical Records

Southcoast Health
Information Management Department
200 Mill Road, Suite 210
Fairhaven, MA 02719
Fax: (508) 973-3695
Email: RequestRecords@southcoast.org
Phone: (508) 973-3733