York Hospital Privacy NoticeThis Notice describes how York may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.
“Protected health information” or “PHI” is individually identifiable health information about you, including demographic information collected from you, that is created or received by York and that relates to (i) your past, present, or future physical or mental health or condition, (ii) the provision of health care to you, or (iii) the past, present or future payment of your health care. PHI also includes any health information and records provided to York by other health care providers and facilities who have provided care to you or are involved in your care.
York Hospital participates in an organized health care arrangement with its affiliated facilities and providers. Accordingly, this Notice applies to and describes the privacy practices of the following York-affiliated facilities, entities, programs, practices and delivery sites (collectively, “York”): See Other York Entities and Service Delivery Site Location/Address Utilizing this Notice of Privacy Practices at the end of this form.
YORK’S DUTIES WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION:
York Hospital is required by law to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices with respect to your PHI, and to notify affected individuals following a breach of unsecured PHI. Although York is required to abide by the terms of the Notice that is currently in effect, we reserve the right to change our privacy practices at any time and to make the new Notice provisions effective for all PHI that we maintain about you. If our privacy practices change, we will provide you with a revised Notice during your next visit.
PROTECTED HEALTH INFORMATION:
York may use and disclose your PHI, without your authorization, for purposes of treatment, payment, and health care operations. For example:
• TREATMENT: York may use or disclose your PHI to other health care providers for treatment and continuity of care purposes and to arrange for the provision, coordination, and management of health care services for you. For example, York may disclose information about your hospital stay to your primary care physician to arrange for appropriate post-hospital care is provided to you following your discharge from the hospital. York may also disclose PHI about you to a pharmacist to process your prescription, or to a medical equipment supplier for supplies and equipment necessary for your care.
• PAYMENT: York may use or disclose PHI about you to your health insurance company or other third-party payor health plans such as Medicare or MaineCare (Medicaid) to obtain payment or reimbursement for health care services provided to you, or to determine your eligibility for coverage and benefits, unless you pay in full out of pocket for services provided to you and request in writing that your PHI not be disclosed to third-party payors.
• HEALTH CARE OPERATIONS: York may use or disclose your PHI for certain health care operations purposes, such as quality review and improvement activities, risk management activities, and to conduct and process patient satisfaction surveys.
• ORGANIZED HEALTH CARE ARRANGEMENT PURPOSES: York entities participating in York’s organized health care arrangement (described below) may share your PHI with each other as necessary to carry out treatment, payment or health care operations relating to the organized health care arrangement.
York may also use and disclose your PHI without your authorization in the following additional circumstances:
• AS REQUIRED BY LAW: York may use and disclose your PHI when required or authorized by state and federal law.
• PUBLIC HEALTH ACTIVITIES: York may use and disclose your PHI to public health authorities for public health activities, such as to comply with mandatory communicable disease and vital statistics reporting laws.
• ABUSE, NEGLECT, AND EXPLOITATION REPORTING: York may disclose your PHI to government authorities, such as Child Protective Services or Adult Protective Services, that are authorized by law to receive reports of actual or suspected cases of abuse, neglect, or exploitation of children and incapacitated or dependent adults.
• HEALTH OVERSIGHT ACTIVITIES: York may use and disclose your PHI to a health oversight agency for activities authorized by law such as compliance with health oversight audits, investigations, licensure surveys and inspections, and compliant investigations. Oversight agencies authorized to receive your PHI include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs, including the Maine Department of Health and Human Services, the federal
AUTHORIZED USES AND DISCLOSURES OF YOUR Medicare program, and Maine health care professional licensing boards.
• JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: York may disclose your PHI in judicial or administrative proceedings when required or authorized by law, for example, in response to an order of a court or pursuant to a subpoena served by a governmental entity authorized by law to have access to your PHI.
• LAW ENFORCEMENT PURPOSES: York may disclose your PHI, so long as applicable legal requirements are met, for certain law enforcement purposes such as to report gunshot wounds, crimes committed on York’s premises, or crimes committed against York personnel.
• CORONERS AND MEDICAL EXAMINERS: York may use and disclose PHI to coroners and medical examiners regarding a deceased patient for identification purposes, or for a coroner or medical examiner to determine a cause of death or to perform other duties authorized by law.
• FUNERAL DIRECTORS: York may use and disclose PHI to funeral directors consistent with applicable law as necessary to carry out their duties with respect to making funeral arrangements for a deceased patient. If necessary to carry out such duties, York may disclose such information prior to and in reasonable anticipation of a patient’s death.
• BODY, ORGAN, EYE OR TISSUE DONATION PURPOSES: York may use and disclose PHI to organ procurement organizations or other entities for cadaveric (body), organ, eye, or tissue donation purposes.
• RESEARCH: York may use and disclose your PHI for research purposes so long as the research and any uses and disclosures related to such research are approved by an Institutional Review Board (IRB) or a Privacy Board and no identifying information about you is disclosed in any report arising from or published in connection with the research.
• USES AND DISCLOSURES TO AVERT THREATS OF HARM OR SAFETY: York may use and disclose your PHI when necessary to prevent or lessen a direct threat of serious, imminent harm to health or safety.
• SPECIALIZED GOVERNMENT FUNCTIONS: York may disclose your PHI for the following specialized government functions when such disclosures are authorized or required by applicable law:
1. Armed Forces and Foreign Military Personnel: York may disclose the PHI of persons who are members of the Armed Forces and of foreign military personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of a military mission.
2. National Security and Intelligence Activities: York may disclose your PHI to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by the National Security Act and related Executive Orders.
3. Protective Services for the President and Others: York may disclose your PHI to authorized federal officials for the provision of protective services to the President or other persons, or for the conduct of investigations, authorized under applicable federal law.
4. Correctional Institutions and Law Enforcement Custodians: York may disclose to a correctional institution or a law enforcement official having lawful custody of an inmate or other individual, PHI about the inmate or other person when necessary (i) to provide health care to the inmate or person in custody, (ii) for the health and safety of the inmate or person in custody, (iii) for the health and safety of correctional personnel, (iv) for the health and safety of persons responsible for transporting the inmate or person in custody, (v) for law enforcement on correctional facility premises, and (vi) for administering and maintaining the safety, security and good order of the correctional institution.
• WORKERS’ COMPENSATION: York may disclose your PHI when authorized by and to comply with comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness without regard to fault.
• BUSINESS ASSOCIATES: York may disclose your PHI to business associate contractors performing services for or on behalf of York when such contractors have agreed in writing to appropriately protect your PHI.
• PERSONAL REPRESENTATIVES: York may disclose your PHI to a personal representative, such as your guardian, health care power of attorney agent, or health care surrogate, who is authorized to make health care decisions on your behalf when you lack the capacity to make your own health care decisions.
• USES AND DISCLOSURES FOR FACILITY DIRECTORY PURPOSES: Unless you or your personal representative notify York that you object to and wish to prohibit or restrict any such uses and disclosures, York may use and disclose the following limited PHI about you for the following facility directory purposes:
1. York may use limited PHI about you to maintain a facility directory—namely, your presence and room location in a York facility, a brief general description of your health status and condition that does not communicate specific medical information about you, and your religious affiliation.
2. York may disclose such facility directory information about you (except for your religious affiliation) to persons who ask for you by name, including members of the public and law enforcement officials.
3. York may also disclose such facility directly information about you, including your religious affiliation, to members of the clergy.
4. York may also disclose a brief general description of your health status and condition that does not communicate specific medical information about you (but not your room number) to members of the media who ask for you by name.
• PERSONS INVOLVED IN YOUR CARE AND USES AND DISCLOSURES FOR NOTIFICATION PURPOSES: York may disclose your PHI to family members, relatives, or close personal friends involved in your care, involved in securing payment for your care, or for notification purposes, unless you or your personal representative notify us that you object to and wish to prohibit or restrict such disclosures.
• DISASTER RELIEF: York may use and disclose your PHI to public or private entities authorized by law to assist in disaster relief efforts for certain notification purposes, provided you have been given the opportunity to agree or to object to such uses and disclosures.
• FUNDRAISING ACTIVITIES: York may use limited PHI about you—namely, your name, address, contact information, age, gender, date of birth, dates of service, department of service, treating physician, outcome information, and health insurance status—to contact you for York fundraising activities in furtherance of York’s nonprofit mission. However, you have the right to opt out of receiving York fundraising communications by notifying York’s Privacy Officer that you do not wish to receive such communications. We may also disclose such limited information to an institutionally related foundation to conduct fundraising activities for the benefit of York.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRING YOUR AUTHORIZATION:
• WRITTEN AUTHORIZATION: For other types of uses and disclosures not described in this Notice of Privacy Practices, York will obtain your written authorization before using or disclosing your PHI. For example, the following uses and disclosures require York to obtain your written authorization:
• Psychotherapy Notes: In the event that York maintains psychotherapy notes about you that are kept separate from the rest of your York medical record, York will obtain your written authorization to use or disclose such psychotherapy notes unless an exception to the authorization requirement applies under applicable law.
• Marketing: York will obtain your written authorization for any use or disclosure of your PHI to sell or market products or services, except in limited circumstances (for example, in face-to-face marketing communications with you).
• Sale of PHI: York will obtain your written authorization for any disclosure of your PHI that involves a sale of your PHI, unless an exception applies under applicable law.
• Photographs and Videorecordings: York will not photograph or videorecord you, or use or disclose any photographs and videorecordings of you, for non-treatment related purposes, for marketing or public relations purposes, without your written authorization, unless the creation, use or disclosure of such photographs or videorecordings are authorized by law (e.g., for York facility security surveillance purposes).
• RIGHT TO REVOKE AUTHORIZATION: You may revoke an authorization to disclose your PHI at any time, to the extent that York or others have not already relied upon your authorization, by giving written notice of your revocation to York’s Privacy Officer.
SPECIAL PROTECTIONS FOR CERTAIN TYPES OF PROTECTED HEALTH INFORMATION:
• CONFIDENTIALITY OF MENTAL HEALTH INFORMATION: If York maintains information about you derived from mental health services provided to you by a York psychiatrist, psychologist, clinical nurse specialist, social worker or counseling professional, York will not disclose such mental health information to another health practitioner or facility outside of York or its organizational affiliates for a diagnostic, treatment or continuity of care purpose, without your written authorization, unless such disclosure is necessary in an emergency or is otherwise authorized or required by law. If a York licensed mental health facility, program or agency maintains mental health information about you, York will not use or disclose such mental health facility PHI about you except as authorized or required by applicable mental health confidentiality laws and regulations.
• CONFIDENTIALITY OF HIV INFORMATION: If York maintains any information regarding your HIV status (such as HIV test results or medical records containing HIV information), such information is afforded heightened protection under Maine law and York will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by Maine’s HIV confidentiality laws.
• CONFIDENTIALITY OF SUBSTANCE ABUSE PROGRAM INFORMATION: If a York substance abuse program maintains, or if York acquires from another provider or facility, any substance abuse PHI about you that is subject to the heightened federal confidentiality protections afforded to certain substance abuse program records under 42 C.F.R. Part 2, York will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by 42 C.F.R. Part 2. If York creates, acquires or maintains any substance abuse information about you that is not from a Part 2 substance abuse program, York will protect the confidentiality of such information and use and disclose such information in the same way York protects, uses and discloses your other PHI.
YOUR RIGHTS WITH RESPECT TO PROTECTED HEALTH INFORMATION: The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.
• YOU HAVE THE RIGHT TO ACCESS, INSPECT AND COPY YOUR PHI. This means you may inspect at reasonable times and obtain a copy of your clinical records and billing records within 30 days of receipt of your written request. If we need extra time, we may extend the time once for an additional 30 days and we will provide you written notice of the extension. You have the right to receive your health information in the form and format of your choosing, if such information can be readily produced in such form and format, or in a readable hardcopy form, or in another format agreed to between you and York. If York maintains your PHI in an electronic health record, you have the right to obtain a copy of your health information in an electronic format and to direct York to transmit an electronic copy of your PHI directly to another clearly specified entity or person of your choice. You may be charged reasonable costs (including labor and supplies) associated with providing copies of your records, or of preparing any summaries that you request. In certain limited circumstances, you may be denied access to your health information and records. However, you may request that a decision denying you access to your PHI and records be reviewed. Please contact York’s Privacy Officer if you have questions about your right to access your PHI.
• YOU HAVE THE RIGHT TO REQUEST A RESTRICTION ON CERTAIN USES AND DISCLOSURES OF YOUR PHI. For example, you may request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. If you request that York not disclose your PHI to a third-party payor health plan for purposes of carrying out payment or health care operations, and you have paid York in full out of pocket for services provided to you, York is required to honor your requested restriction. Otherwise, York is not required to agree to a requested restriction and has sole discretion to decide whether to honor a requested restriction on a case-by-case basis. If York agrees to a requested restriction, York will not use or disclose your PHI in violation of the agreed upon restriction, unless the use or disclosure is needed to provide emergency treatment. Your request for a restriction must state the specific restriction requested and to whom you want the restriction to apply. Disclosures of PHI authorized by you or permitted or required by law as described in this Notice, may include disclosures of PHI York has received from other health care providers and facilities, unless you request and York agrees to a requested restriction on the disclosure of such information.
• YOU HAVE THE RIGHT TO REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATIONS OF PHI FROM US BY ALTERNATIVE MEANS OR AT AN ALTERNATIVE LOCATION. York will accommodate reasonable requests. York may place conditions on such accommodations, for example, by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. York will not request an explanation from you as to the basis for the request. Please make such requests in writing to York’s Privacy Officer.
• YOU HAVE THE RIGHT TO SUBMIT AMENDMENTS, CORRECTIONS AND CLARIFICATIONS TO YOUR PHI. You may request amendments, corrections and clarifications to PHI contained in your medical records. Your request must be in writing and you must provide a reason supporting your request. If you are requesting a change to the PHI in your treatment record, we will place your requested amendment, correction or clarification in your record. York may add a response to your record, and will provide to you a copy of our response. If you are requesting a change in other records (that are neither medical or billing records), York may deny your request. If your request is denied, we will notify you in writing and provide our reasons for the denial. You have the right to file a statement of disagreement with York’s Privacy Officer and York may prepare a response to your statement. York will provide you with a copy of our response. Please contact York’s Privacy Officer if you have any questions about modifying your PHI.
• YOU HAVE THE RIGHT TO RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES. You have the right to receive an accounting of certain disclosures of your PHI made by York in the six years prior to the date of your request. The accounting will not include disclosures made directly to you, disclosures made to others pursuant to your written authorization, disclosures made to carry out treatment, payment, and health care operations for which your written authorization was not required, incidental uses and disclosures, and uses and disclosures for which an accounting is not required by law. However, you have the right to request an accounting of disclosures made for purposes of treatment, payment, or health care operations through an electronic health record during the three years prior to your request. To request an accounting of disclosures of your PHI, contact York’s Privacy Officer.
• IMPORTANT NOTICE TO MINORS REGARDING MINOR’S PRIVACY RIGHTS: If you are a minor authorized by law to consent to health care services on your own behalf and you in fact consent to such services on your own behalf, York is required to protect the privacy of your PHI with respect to health care services you have consented to on your own behalf in the same way that York protects the privacy of an adult’s PHI, unless a special exception applies under the law. For example, York is authorized by law to notify your parent or guardian if, in the judgment of your York provider failure to inform your parent or guardian would seriously jeopardize your health or would seriously limit the ability of your York provider to provide treatment to you. Additionally, if you want York to bill your parent’s insurance for services provided to you, your parents will receive from their insurance company an Explanation of Benefits regarding the services provided to you by York and, as a result, the fact that you received services from York will not be confidential from your parents. However, if you do not want your parents to know that you are receiving services from York, you must notify York of that fact at the time services are provided to you so that arrangements can be made for payment of such services privately or out-of-pocket, or to determine your eligibility for free or discounted care.
• YOU HAVE THE RIGHT TO OBTAIN A PAPER COPY OF THIS NOTICE FROM US, UPON REQUEST, even if you have agreed to accept this Notice electronically.
• YOU HAVE THE RIGHT TO FILE A COMPLAINT. You have the right to file a complaint with York or the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by York. You may file a complaint with York by notifying York’s Privacy Officer using the contact information provided below. York will not retaliate against you in any way for filing a complaint.
CONTACTING YORK’S PRIVACY OFFICER
FOR MORE INFORMATION:
If you have any questions about this Notice,
or would like more information about York’s privacy practices, please contact York’s Privacy Officer at:
York Hospital Privacy Officer
15 Hospital Drive, York, Maine 03909
Phone: (207) 351-2139 email: email@example.com
15 Hospital Drive, York, ME 03909 (207) 363-4321 | toll free 877-363-4321
LIST OF YORK ENTITIES AND SERVICE DELIVERY SITE
LOCATION/ADDRESS OF PRIVACY PRACTICES
YORK HOSPITAL CAMPUS
• York Hospital: 15 Hospital Dr, York, ME 03909 [main building]
• Erwin Medical Office Building: 2 Hospital Dr/233 York Street, York Maine 03909 [Webhannet Internal Medicine - York, Neurology Associates of YH]
• Ulan Medical Office Building: 12 Hospital Dr, York, ME 03909 [Pulmonary Associates of YH, York Plastic Surgery/Aesthetics, General Surgery Associates of YH, Cardiovascular Care of York Hospital.
• Warner Medical Office Building: 16 Hospital Dr, York, ME 03909 [Orthopaedic Associates of YH, Pediatric Associates of YH, YH OBGYN, Surgical & Midwifery Assoc, Cottage Program]
• York Hospital at Long Sands: 127 Long Sands Rd (Stes 7A, 7B, 9, 11, 12), York, ME 03909 [Oncology & Infusion - York, Home Care & Hospice, York Family Practice, Physical Therapy - York]
• York Hospital Community Health & Psychiatry Associates of York Hospital: 32 York St, York, ME 03909
• Urology Associates of York Hospital: 16 Long Sands Rd, York, Maine 03909
• York Hospital in Wells: 112 & 114 Sanford Rd, Wells, ME 04090 [Cardiovascular Care, Myhealth@Wells, Wells Emergency Care, Lab, Imaging, Wound Healing, Breast Care - Wells, Physical Therapy - Wells, OBGYN -Wells, Pediatrics - Wells, Oncology - Wells]
• Webhannet Internal Medicine: 277 Post Rd, Moody, ME 04054
• York Hospital in Berwick: 4 Dana Dr, Berwick, ME 03901 [Myhealth@Berwick, Lab, X-ray, Berwick Pharmacy]
• York Hospital in North Berwick: 23 Wells St, North Berwick, ME 03906 [Webannet Internal Medicine - North Berwick]
• York Hospital in South Berwick: 57 Portland St, South Berwick, ME 03908 [Great Works Family Practice, Lab, X-ray, Physical Therapy - South Berwick, Pediatric Physical Therapy, Oncology - South Berwick, OBGYN - South Berwick]
• York Hospital in Kittery: 35 Walker St, Kittery, ME 03904 [Myhealth@Kittery, Lab, X-ray, Kittery Family Practice]
• Oncology & Physical Therapy: 75 US Route 1 Bypass, Kittery, ME 03904
• Cardiovascular Care of NH & York Hospital: 7 Works Way, Somersworth, NH 03878
• Cardiovascular Care of NH & York Hospital:, 2064 Woodbury Ave, Newington, NH 03802
15 Hospital Drive, York, ME 03909 (207) 363-4321 | toll free 877-363-4321
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