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Notice of Privacy Practices, Patient Brochure (pdf document)
HIPAA Policy Regarding Patient Authorization for Disclosure (pdf document)
Patient Authorization Form (pdf document)
This Notice describes the privacy practices of Massachusetts Eye and Ear Infirmary (MEEI) and its medical staff, Massachusetts Eye and Ear Associates, Inc. (MEEA), and their physicians, nurses and other personnel. MEEI and MEEA constitute a single affiliated covered entity for purposes of the Federal Privacy Rule and this Notice.
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 Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
In certain situations, which we will describe in Sections 4 and 5, we must obtain your written consent or authorization in order to use and /or disclose your Protected Health Information. However, we do not need any type of consent or authorization from you for the following:
We may use (but not disclose to a third party) your PHI in order to treat you, obtain payment for services provided to you and conduct our "health care operations" as detailed below:
We may include your name, location in Hospital, general health condition and religious affiliation in a patient directory without obtaining your written consent or authorization unless you object to inclusion in the directory. Your location will not be included in the directory if you are located in a specific area or unit that would identify information about your condition or treatment. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.
We may disclose your PHI, other than Highly Confidential Information (described below in Section 4.B) to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, and do not object to such disclosure after being given the opportunity to do so. We may also disclose your PHI to such persons with your verbal agreement or written consent.
If you are incapacitated or in an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person's involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
We may contact you to request a tax-deductible contribution to support important activities of Hospital. In connection with any fundraising, 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 consent or authorization. If you wish to make a tax-deductible contribution now or do not want to receive any fundraising requests in the future, you may contact our Development Office at 617-573-3345.
We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect, elder abuse, and disabled persons abuse to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) if we know or have reason to believe that you are infected with a venereal disease, to alert your fiancée (if you are engaged) or your spouse (if you are married), or your parent or guardian (if you are a minor, unless as a minor you have sought treatment with us for such venereal disease); (5) to report information to your insurer and/or the Massachusetts Division of Industrial Accidents as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; (6) to report information related to the birth and subsequent health of an infant to state government agencies as required by law; and (7) to file a death certificate and report fetal deaths
We may disclose your PHI to a health oversight agency that oversees the health care system or government benefit programs (such as Medicare or Medicaid).
We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
We may disclose your PHI to a coroner or medical examiner as authorized by law.
If you are an organ donor, we may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
We may use or disclose your PHI without your consent or authorization for research purposes if our Institutional Review Board approves a waiver of authorization for such use or disclosure. In addition, certain elements of your PHI may be reviewed by our clinicians, employees or workforce to determine your potential eligibility for one or more clinical research trials, and we may contact you via phone to determine your willingness to participate.
We may use or disclose your PHI to prevent or lessen a serious danger to you or to others.
We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
We may disclose PHI when required to report findings from an examination ordered by a court or detention facility.
We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
With your written consent, or as otherwise permitted by Massachusetts law and consistent with prior MEEI/MEEA practice, we may disclose PHI in order to treat you, obtain payment for services provided to you and conduct our health care operations as detailed below:
If you are an emancipated minor, certain information relating to your treatment or diagnosis will not be disclosed to your parent or guardian without your consent. Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered. Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification.
Please note that if you are a parent or legal guardian of an emancipated minor, certain portions of the emancipated minor's medical record (or, in certain instances, the entire medical record) may not be accessible to you.
For any purpose other than those described above in Section 3 (for which no consent or authorization is required) and Section 4 (for which your consent is required), we only may use or disclose your PHI when you give us your written authorization on our authorization form ("Your Authorization") (an authorization form is similar to a consent form, but is more detailed and specific than a general consent form). For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company. In addition, under certain circumstances, we may need to obtain Your Authorization to use or disclose psychotherapy notes contained in your medical record, if any.
We must also obtain your written authorization prior to using your PHI to send you any marketing materials ("Your Marketing Authorization"). We can, however, use (but not disclose to a third party) your PHI to provide you with marketing materials in a face-to-face encounter without obtaining Your Marketing Authorization. We are also permitted to use (but not disclose to a third party) your PHI to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization. In addition, we may use (but not disclose to a third party) your PHI to communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization, and we may use your PHI to identify health-related services and products that may be beneficial to your health and then contact you about the services and products.
Federal and state law require special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including: (1) your HIV/AIDS status; (2) genetic testing information; (3) confidential communications with a psychotherapist, psychologist, social worker, allied mental health professional, or human services professional; (4) substance abuse (alcohol or drug) treatment or rehabilitation information; (5) venereal disease information; (6) family planning services; (7) mental health community program records; and (8) research involving controlled substances.In order for us to disclose your Highly Confidential Information we must obtain your separate, specific authorization, unless we are otherwise permitted by law to make such disclosure.
If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
You may request restrictions on our use and disclosure of your PHI: (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.
You may request, and we will accommodate, any reasonable written request to receive your PHI by alternative means of communication or at alternative locations.
You may revoke Your Consent, Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information at any time, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below. A form of Written Revocation is available upon request from the Privacy Office.
You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge you a cost based fee of $12 for the first page and .50cents for each additional page, which represents the supply and labor costs of copying.. We will also charge you for our postage costs, if you request that we mail the copies to you.
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 Privacy Office and submit the completed form to the Privacy Office. 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.
Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you a cost based fee of $12 for the first page and .50 cents for each additional page which represents supply and labor costs of copying.
Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
This Notice is effective on April 14, 2003.
We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around MEEI, its satellites and on our Internet site at www.meei.harvard.edu. You also may obtain any new Notice by contacting the Privacy Office.
You may contact the Privacy Office at:
Massachusetts Eye and Ear Infirmary
Privacy Office
243 Charles Street
Boston, MA 02114
Telephone Number: (617) 263-1600
E-mail: privacy_office@meei.harvard.edu
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