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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY Planned Parenthood of Metropolitan NEW JERSEY, Inc. (ppmnj) AND HOW TO ACCESS THIS INFORMATION
 
Effective Date Of This Notice: April 14, 2003

PLEASE REVIEW THIS NOTICE CAREFULLY
 
OUR PLEDGE REGARDING YOUR HEALTH________ INFORMATION
We understand that information about you and your healthcare is personal. We are committed to protecting health information about you. 
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe different ways that we may use or disclose health information about you. Unless otherwise noted each of these uses and disclosures may be made without your permission. For each category of use or disclosure, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, unless we ask for a separate authorization, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use health information about you to provide you with treatment and services. We may disclose your information to doctors, nurses, technicians, health students, volunteers or other personnel involved in taking care of you. They may work at our offices, at a hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other healthcare provider to whom we may refer you for consultation, x-rays, lab tests, to have prescriptions filled, or other treatment. For example, a doctor treating you may need to know if you have diabetes because diabetes may slow the healing process. We may provide that information to a physician treating you at another institution.
For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, a state Medicaid agency or a third party. For example, we may need to give your health insurance plan information about your office visit so that they will pay us or reimburse you for the visit. Alternatively, we may need to give your health information to the state Medicaid agency so that we may be reimbursed for providing services to you. In some instances, we may need to tell your health plan about a treatment you are going to receive to obtain approval or to determine whether your plan will cover the treatment.
For Healthcare Operations: We may use and disclose health information about you for operations of our healthcare practice. These uses and disclosures are necessary to run our practice and ensure that all patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, which are not needed, whether certain new treatments are effective, or to compare how we are doing with others to see where we can make improvements. We may remove information that identifies you from this set information so others may use it to study healthcare delivery without learning who our patients are.
Appointment Reminders: We may use and disclose health information to contact you as a reminder of an appointment. Please let us know if you do not wish to have us contact you concerning your appointment, or if you wish to use a different telephone number or address for contact purposes.
As Required By Law. We will disclose health 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 health 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.
Military and Veterans. If you are a member of the armed forces or are separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.
Workers' Compensation. We may release health 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 health information about you for public health activities. These activities generally include:
·        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 people of recalls of products they may be using;
 
·        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;
 
·        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.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, inspections, and licensure. This is necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and DisputesIf you are involved in a lawsuit or dispute, we may disclose health information about you in response to an order issued by a court or administrative tribunal. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone involved in the dispute, but only after efforts have been made to tell you about the request and you have time to obtain an order protecting the information requested.
Law Enforcement. We may release health 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;
·   If you are the victim of a crime and, if under limited circumstances we are unable to obtain your consent;
·   About a death we believe may be the result of criminal conduct;
·   In an instance of criminal conduct at our facility; 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, Health Examiners and Funeral Directors. We may release health information to a coroner or health examiner. This may be necessary, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with healthcare; (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.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy: You have certain rights to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records but this does not include psychotherapy notes.
 
To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing on a form provided by us to: “The Privacy Official at PPMNJ”.   If you request a copy of your health information, we                may charge a fee for the costs of locating, copying, mailing or other supplies and services associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may in certain instances request that the denial be reviewed. Another licensed healthcare professional chosen by PPMNJ will review your request and the denial. The person conducting the review will not be the person who denied your initial request. We will comply with the outcome of the review.
Right to Amend. If you feel that health 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 on a form provided by us and submitted to: “The Privacy Official at PPMNJ”.
We may deny your request for an amendment if it is not the form provided by us and 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 health information kept by or for PPMNJ;
·     Is not part of the information you would be permitted to inspect and copy; or
·     Is accurate and complete.
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.
Right to an Accounting of Disclosures. You have the right to request a listing of any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described, or pursuant to an authorization you have provided.
To request this listing, you must submit your request on a form that we will provide to you. Your request should be forwarded to PPMNJ’s Privacy Official and must state a time period that may not be longer than six years and may not include dates before April 14, 2003 [The compliance date of the Privacy Regulation]. The first list of disclosures 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 and you may choose to withdraw or modify your request before any costs are incurred. We will mail you a list of disclosures within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; this date should not exceed a total of 60 days from the date of your request.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health 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 information we disclose about you to someone who is involved in your care or the payment for your care. For example, you could ask that access to your information be denied to a member of our workforce whom you know personally.
While we will try to accommodate your request for restrictions, we are not required to do so if it is not feasible for us to ensure our compliance with law or we believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request on a form that we will provide you. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain manner or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. During our intake process, we will ask you how you wish to receive communications about your health care or for any other instructions notifying you about your health information. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice at any time upon request.  You may also obtain a copy on our website; www.ppmnj.org.
MINORS AND PERSONS WITH GUARDIANS
If you are a minor under the age of eighteen, your parent or legal guardian may have the right to access your medical record and make certain decisions regarding the uses and disclosures of your health information if your treatment does not fall within certain limited categories of care. There are also circumstances when the law requires reporting of abuse and neglect. “However it is also important for you to know that our federal funding requirements: (a) prohibit us from requiring written consent of your parent or guardian before we provide you with Title X family planning services, (b) prohibit us from notifying your parent or guardian before or after you have requested and received Title X family planning services unless we first obtain your written consent, and (c) prohibit us from disclosing information that we obtain about you in connection with Title X family planning services unless we first obtain your written consent.
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 health 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 facility. The Notice contains the effective date on the first page.
 
COMPLAINTS_________________________________
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact : “The Privacy Official at Planned Parenthood of Metropolitan New Jersey” at (973) 622-3900 ext. 219. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
 
OTHER USES OF HEALTH INFORMATION________
Other uses and disclosures of health 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 health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health 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 the records of the care that we provided to you.
 
I-102
10-03

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