Notice of Privacy Practices
Effective Date: April 15, 2003, Revised September, 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.
This Privacy Notice is also on display and available at all Southcoast locations.
If you have any questions about this notice, please contact the Privacy Hotline at 508-973-3682.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal.
We understand that medical 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 are referring to the 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.; Southcoast Primary Care, Inc.; and Southcoast Physician Services, 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. We also describe your rights and certain obligations regarding the use and disclosure of medical information.
It is our responsibility and we are required by law to:
- make sure that medical information that identifies you is kept private;
- give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of this notice that are listed below.
- any health care professional authorized to enter information into our electronic health record ("EHR"), including the doctors on our Hospital 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; and
- any trainee or student who we allow to help you while you are in our Hospital or being treated at Southcoast.
- 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
- Other uses of medical information.
1. How we may use and disclose medical information about you
Southcoast uses several electronic systems to use and maintain an EHR. Information in your EHR may be shared with other providers using the same electronic systems. 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 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 family members, clergy or others we may use to provide services that are part of 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 or a third party. We may also share your medical information with doctors, nurses, technicians and other healthcare personnel who are involved in your treatment at our facilities as necessary for payment activities related to their joint provision of health care.
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 Services. 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 see where we can make improvements in the care and services we offer.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with the patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project.
Appointment Reminders, Treatment Alternatives, Health-Related Benefits and Services. We may from time to time contact you via the telephone to remind you of an appointment or to inform you of treatment alternatives or other healthcare benefits and services that might be of interest to you. If you are not home and you have an answering machine or voice mail, it is likely that the system staff will leave a message for you. We may also use and disclose medical information to tell you about or recommend possible treatment options, alternatives, health related benefits or services that may be of interest to you.
Fundraising Activities. Southcoast is a not-for-profit charitable organization. We may use medical information about you to contact you in an effort to raise money for our organization. We may disclose 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 and the dates you received treatment or services at our facilities. If you do not want us to contact you for fundraising efforts, you must notify the External Affairs at Southcoast Hospitals Group, 141 Page Street, New Bedford, MA 02740 in writing.
Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at our Hospital. 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 also 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.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the Hospital. 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.
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical 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 someone able to help prevent the threat.
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.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
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 Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify a person who may have been exposed to a disease or may be at a risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose medical information to a health oversight agent for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process;
- to identify or locate a suspect, fugitive, material witness, or missing person;
- about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
- about a death we believe may be the result of criminal conduct;
- about criminal conduct at Southcoast; and
- in emergency 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 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 of the Hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may release medical 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 medical information about you to authorized federal officials so they may provide protection to the President and other authorized persons or foreign heads of state, and so that they may conduct special investigations.
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) for the institution 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.
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 copy medical information that may be used to make decisions about your care. Usually, this includes medical records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the appropriate contact listed on the last page of this notice. If you request a copy of the information, we will charge a fee for the cost of copying, mailing, or other supplies associated with your request. If we maintain your health 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. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Southcoast 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. 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 for as long as we keep the information. To request an amendment, your request must be made in writing and submitted to the appropriate contact listed on the last page of this notice. In addition you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- is not part of the medical information kept by or for our facilities;
- is not part of the information which you would be permitted to inspect and copy; or
- is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made, or our business associates made, of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the appropriate contact listed on the last page of this notice. You may request such information for the six year period prior to the date of your request. Accounting of disclosures will not include disclosures: (1) for payment, treatment or health care operations; (2) made to you or your personal representative; (3) that you authorized in writing; (4) made to family and friends involved in your care or payment for your care; (5) for research, public health, or our business operations; (6) made to federal officials for national security and intelligence activities; and (7) made to correctional institutions or law enforcement officers regarding inmates. 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 the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation 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 are not required to agree to your request unless your request is with respect to restricting disclosure of your health 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. To request restrictions, you must make your request in writing to the appropriate contact listed on the last page of this notice. In your request, you must tell us (1) the 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 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 not ask you the reason for your request and we will accommodate all reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website, www.southcoast.org. To obtain a paper copy of this notice, you may contact the appropriate contact listed on the last page of this notice.
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, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to our Hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
5. Southcoast Hospital's Group Record Retention Policy
In accordance with the Hospital's policy regarding records retention, the Hospital will retain your medical records for at least 20 years after the discharge from or the final treatment by the Hospital.
If you believe your privacy rights have been violated, you may file a complaint with Southcoast's Privacy Officer or with the Secretary of the Department of Health and Human Services. You may also contact the Privacy Hotline at 508-973-3682. You will not be penalized for filing a complaint.
7. Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission at any time by writing to the appropriate contact listed on the last page of this notice. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Southcoast Hospitals Group
(Charlton Memorial, St. Luke's and Tobey Hospitals)
101 Page Street
New Bedford, Massachusetts 02740
Southcoast Visiting Nurse Association Inc.
200 Mill Road
Fairhaven, MA 02719
Southcoast Primary Care and Southcoast Physician Services
300A Faunce Corner Road
No. Dartmouth, MA 02747