NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Martha Jefferson Health Services and its Departments, employees, Medical Staff, and other health care professionals (collectively “Martha Jefferson”) are committed to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our general duties and privacy practices with respect to protected health information. This Notice applies to all records of your care generated by Martha Jefferson, whether created by Martha Jefferson employees or members of the Medical Staff. In addition, any business associates or partners with whom we share protected health information will follow terms and conditions of this Notice. Please note that your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of medical information created in the doctor’s office.

We are required by law to abide by the terms of this Notice, and we reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at Martha Jefferson facilities and will make paper copies of this Notice of Privacy Practices for Protected Health Information available upon request.

How Your Medical Information Will Be Used and Disclosed:

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, clinical students, or other Martha Jefferson personnel who are involved in your care at Martha Jefferson. For example, a doctor treating you for a broken leg may need to know if you have diabetes because it may slow the healing process. The doctor may also need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. In addition, we may share medical information about you with your other treating providers upon their request or by permitting them access to our shared practice management computer system or similar computer systems. Different departments of Martha Jefferson may also share medical information about you in order to coordinate the things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside Martha Jefferson who may be involved in your medical care after you leave Martha Jefferson, such as family members, clergy or others who provide services that are part of your care.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at Martha Jefferson may be billed to, and payment may be collected from you, an insurance company or a third party. For example, you may need to give your health plan information about surgery you received at Martha Jefferson 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 in order to obtain prior approval or to determine whether your plan will cover the treatment. Finally, we may disclose information about you to your treating providers for their payment purposes. This may also include sharing information with them through our shared practice management computer system or similar computer systems.

For Health Care Operations. We may use and disclose medical information about you for Martha Jefferson operational reasons such as quality improvement, utilization review, or legal review. These uses and disclosures are necessary to run Martha Jefferson and make sure that all of our patients receive quality care. For example, we may use and disclose medical information to review our treatment and services and to evaluate the performance of our staff in caring for you, or to accrediting agencies that evaluate our performance. We may also combine medical information about many Martha Jefferson patients to evaluate current services, decide what additional services Martha Jefferson should offer, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, clinical students, and other Martha Jefferson personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others can use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use your medical information in order to contact you and provide a reminder that you have an appointment for treatment or medical care. For example, these reminders may be provided by postcard or telephone, or a message left on your answering machine.

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Fund-raising Activities. We may disclose information to the Martha Jefferson Hospital Foundation that is related to Martha Jefferson so that the Foundation may contact you about raising money for Martha Jefferson. We would only release contact information, such as your name, address and phone number and the dates you received treatment or services at Martha Jefferson. If you do not want Martha Jefferson to contact you for fund-raising efforts, you must notify our Privacy Officer in writing at the address listed at the end of this Notice.

Martha Jefferson Directory. We may include certain limited information about you in the Martha Jefferson directory while you are a patient at Martha Jefferson. This information may include your name, location in Martha Jefferson, your general condition (e.g., fair, stable, etc.) and your religious affiliation. This directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This will allow your family, friends, and clergy to visit you in Martha Jefferson and generally know how you are doing. We will ask your permission before we include this information in the directory.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to friends or family members who are 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 Martha Jefferson. If possible, we will ask your permission prior to discussing your care with others. 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.

Other Uses and Disclosures. In addition to the uses and disclosures mentioned previously, we may also use and/or disclose your information in accordance with federal and state laws for the following purposes:

• We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of Martha Jefferson’s compliance with relevant laws.
• We may use or disclose your medical information for public health activities, including: the reporting of disease, injury, or disability, the reporting of domestic violence or child abuse or neglect, and the conduct of public health surveillance, investigation and/or intervention.
• We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
• We may disclose your medical information in the course of certain judicial or administrative proceedings.
• We may disclose your medical information for law enforcement purposes such as complying with a court order, subpoena or warrant, and other law enforcement purposes.
• We may disclose your medical information to a coroner, medical examiner or a funeral director.
• If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.
• We may use or disclose your medical information to researchers conducting research that has been approved by an Institutional Review Board or Martha Jefferson’s privacy board.
• We may use or disclose your medical information to appropriate persons to prevent or lessen a serious threat to the health or safety of another person or the public.
• We may use or disclose your medical information for military, national security, prisoner, and government benefits purposes. Note that disclosures for government benefits purposes are limited to health plans only.
• We may disclose your medical information as authorized by laws relating to workers’ compensation or similar programs.
• We may use and/or disclose your medical information as may otherwise be required under federal or state law, including but not limited to disclosures under the Virginia Health Records Privacy Act.

When We May Not Use Your Medical Information:

Except as described in this Notice, we will not use or disclose your medical information for any other purpose without your written authorization. If you do provide us with an authorization, you may revoke your authorization in writing at any time.

Your Rights Regarding Your Medical Information:

You have the following rights with respect to your medical information:

• You have the right to request restrictions on certain uses and disclosures of your medical information. However, we are not required to agree with your requested restriction.
• You have the right to receive communications in a confidential manner.
• You have the right to inspect and obtain a copy of your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.
• You have the right to request an amendment of your medical information. We may deny your request for certain specific reasons, and, if denied, we will provide you with a written explanation for the denial and information regarding further rights you would have at that point.
• You have the right to receive an accounting of the disclosures of your medical information made by us in the six years prior to your request, except for disclosures of treatment, payment or operational purposes, and for certain other specific disclosure types.
• You have the right to request a paper copy of this Notice of Privacy Practices for Protected Health Information.
• You have the right to complain to Martha Jefferson, Virginia Department of Health and/or the United States Department of Health and Human Services if you believe that Martha Jefferson has violated your privacy rights. To complain to Martha Jefferson, please contact the Martha Jefferson’s Privacy Officer at (434) 982-8329 or by writing to Martha Jefferson Hospital Compliance, 459 Locust Avenue, Charlottesville, VA 22902. If you choose to file a complaint, you will not be retaliated against in any way.

If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact Martha Jefferson’s Privacy Officer at (434) 982-8329 or Martha Jefferson’s Compliance Officer at (434) 982-8451. You may also contact us by writing to Martha Jefferson Hospital Compliance, 459 Locust Avenue, Charlottesville, VA 22902.

THIS NOTICE IS EFFECTIVE AS OF JUNE 30, 2005.