Notice of Privacy Practices
Released September 23, 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.
If you have any questions about this Notice, please contact
our Privacy Officer at the number listed at the end of this Notice.
Each time you visit a healthcare provider, a record of your
visit is made. Typically, this record contains your symptoms, examination and
test results, diagnoses, treatment, a plan for future care or treatment, and
billing-related information. This Notice applies to all of the records of your
care generated by your Fenway Health provider.
Fenway Health is required by law to maintain the privacy of your health
information and to provide you with a description of our legal duties and
privacy practices regarding your health information. Our current Notice will be
available in the main reception area and on our website at
www.fenwayhealth.org. The Notice will include the effective date and
version. In addition, at your initial visit, we will make our best effort to
provide you with a copy of this notice and we will request you acknowledge
receipt of the Notice with your signature.
We are required by law to abide by the terms of this Notice
and notify you if we make changes to this Notice, which may be at any time.
Changes to the Notice will apply to your medical information that we already
maintain as well as new information received after the change occurs. You may
also request a revised Notice at your next appointment or appropriate visit.
This Notice will also serve to advise you as to your rights with regard to your
How We May Use and Disclose
Medical Information About You
The following categories describe examples of the way we use and disclose
medical information. These examples are
not meant to be exhaustive, but rather to describe for you the types of uses
and disclosures that may be made:
- For Treatment: We may use medical
information about you to provide, coordinate and manage your treatment or
services. We may disclose medical information about you to other doctors,
nurses, technicians, medical students, or other personnel who are involved in
your care. For example, a laboratory or medical specialist may need to
know information about you to run tests or to provide treatment. We may also
provide a subsequent healthcare provider with copies of various reports that
should assist him or her in treating you. For example, your medical information
may be provided to a physician to whom you have been referred so as to ensure
that the physician has appropriate information regarding your previous
treatment and diagnosis. The amount of information shared will be the “minimum
necessary” for a healthcare provider to make informed decisions about your
- For Payment: We may use and
disclose medical information about your treatment and services to bill and
collect payment from you, your insurance company or a third party payer.
For example, we may need to give your insurance company information before it
approves or pays for the health care services we recommend for you. The
insurance company may use that information in connection with making a determination
of eligibility or coverage for insurance benefits, reviewing services provided
to you for medical necessity, and undertaking utilization review activities.
For example, obtaining approval for a hospital stay may require that your
relevant protected health information be disclosed to the health plan to obtain
approval for the hospital admission.
- For Health Care Operations: We may use or
disclose, as needed, your health information in order to support our business
activities. These activities may include, but are not limited to quality
improvement activities, employee review activities, training of medical
students, licensing, marketing, fundraising, legal advice, accounting support,
medical records storage, transcription and conducting or arranging for other
business activities. For example, we provide medical records to a storage
company for long-term safekeeping. In addition, we may also call you by name in
the waiting room when your physician is ready to see you. We may use or
disclose your protected health information, as necessary, to contact you to
remind you of your appointment by telephone.
- Research: We may use your PHI
for research purposes when our Institutional Review Board has reviewed the
research proposal and approved the research based on established protocols to
ensure the privacy of your PHI.
- Business Associates: There are some
services provided in our organization through contracts with third parties,
which we refer to as business associates. Examples include accounting, legal
services and record storage. When these services are contracted, we
may disclose your health information to our business associate so that they can
perform the job that we have asked them to do or to bill you or your
third-party payer for services rendered. To protect your health information,
however, we require the business associate to appropriately safeguard your
information through a written contract.
Other Permitted and Required Uses and
Disclosures That May Be Made With Your Consent, Authorization or Opportunity to
We also may use and disclose your health information as set
forth below. You have the opportunity to agree or object to the use or
disclosure of all or part of your health information in these instances. If you
are not present or able to agree or object to the use or disclosure of the
health information (such as in an emergency situation), then your clinician
may, using professional judgment, determine whether the disclosure is in your
best interest. In this case, only the
information that is relevant to your health care will be disclosed.
- Individuals Involved in Your Care or
Payment for Your Care: Unless you object, we may disclose medical information
about you to a friend, family member or any other person you identify who is
involved in your medical care or who helps to pay for your care. 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. If you are unable
to agree or object to such a disclosure, we may disclose such information as
necessary if we determine that it is in your best interests, based on our
professional judgment. We may use or
disclose protected health information to notify or assist in notifying a family
member, personal representative or any other person that is responsible for
your care of your location, general condition or death. Finally, we may use or disclose your
protected health information to an authorized public or private entity to
assist in disaster relief efforts and to coordinate uses and disclosures to
family or other individuals involved in your health care.
- Emergencies: In an emergency treatment situation, we may
have to use or disclose your protected health information in a context in which
consent for the release of information has not already been given. If this happens, we will try to obtain your
consent to the release of information as soon as reasonably practicable after
the delivery of the treatment. If we are
required to treat you and have attempted to obtain your consent but are unable
to obtain your consent, we may still use or disclose your protected health
information to treat you.
- Future Communications: We may
communicate to you via newsletters, mailings or other means regarding treatment
options; information on health-related benefits or services, disease-management
programs, wellness programs; to assess your satisfaction with our services; to
remind you that you have an appointment for medical care; as part of
fundraising efforts; for population based activities relating to improving
health or reducing health care costs; for conducting training programs or
reviewing competence of health care professionals; or other community based
initiatives or activities in which our facility is participating. If you
are not interested in receiving these materials, please contact our Privacy
- Research: We may disclose information to
researchers when the research has been approved by an institutional review
board that has reviewed the research proposal and established protocols to
ensure the privacy of your health information.
This also may include preparing for research or telling you about
research studies that might interest you.
Other Permitted and Required Uses and
Disclosures That May Be Made Without Your Consent, Authorization or Opportunity
There are other circumstances in
which we may have to use or disclose your protected health information, even
without your consent or authorization.
These situations include:
- Communication Barriers: If we attempt to obtain consent
from you but is unable to do so due to substantial communication barriers and we
determine, using professional judgment, that you would consent to the use or
disclosure under the circumstances, we may use and disclose your protected
- Disclosure Required By Law: We may use or disclose your
protected health information to the extent that the use or disclosure is
required by law. The use or disclosure
will be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be
notified, as required by law, of any such uses or disclosures.
- Public Health: We may disclose your protected
health information for public health activities and purposes to a public health
authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose
of controlling disease, injury or disability.
We may also disclose your protected health information, if directed by
the public health authority, to a government agency that is collaborating with
the public health authority.
- Communicable Diseases: We may disclose your protected
health information, if authorized by law, to a person who may have been exposed
to a communicable disease or may otherwise be at risk of contracting or
spreading the disease or condition.
- Health Oversight: We may disclose protected health
information to a health oversight agency for activities authorized by law, such
as audits, investigations, and inspections.
Oversight agencies seeking this information include government agencies
that oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
- Abuse or Neglect: We may disclose your protected
health information to a government authority that is authorized by law to
receive reports of child abuse or neglect.
In addition, we may disclose your protected health information if we
believe that you have been a victim of abuse, neglect or domestic violence to
the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
- Food and Drug Administration: We may disclose your protected
health information to a person or company required by the Food and Drug
Administration to report adverse events, product defects or problems, biologic
product deviations, track products; to enable product recalls; to make repairs
or replacements; or to conduct post marketing surveillance, as required.
- Legal or Administrative Proceedings or
Investigations: We may
disclose protected health information in the course of any judicial or
administrative proceeding or investigation, in response to an order of a court
or administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to a subpoena, discovery request
or other lawful process or request.
- Law Enforcement: We may disclose protected health
information, so long as applicable legal requirements are met, for law
enforcement purposes. These law
enforcement purposes include requests:
(1) pursuant to legal processes or as otherwise required by law; (2) for
limited information for identification and location purposes; (3) pertaining to
potential victims of a crime; (4) relating to suspicion that a death has
occurred as a result of criminal conduct; (5) in the event that a crime occurs
at Fenway Health; or (6) relating to a medical emergency (not at Fenway Health)
and it is necessary to alert law enforcement regarding a potential crime.
- Coroners, Funeral Directors, and Organ
Donation: We may
disclose protected health information to a coroner or medical examiner for
identification purposes, determining cause of death or for the coroner or
medical examiner to perform other duties authorized by law. We may also disclose protected health
information to a funeral director, as authorized by law, in order to permit the
funeral director to carry out his/her duties.
We may disclose such information in reasonable anticipation of
death. Protected health information may
be used and disclosed for cadaveric organ, eye or tissue donation purposes.
- Threat to Public Safety: Consistent with applicable
federal and state laws, we may disclose your protected health information, if
we believe that the use or disclosure is necessary to prevent or lessen a
serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to identify or
apprehend an individual.
- State-Specific Requirements: Many states have
requirements for reporting including population-based activities relating to
improving health or reducing health care costs.
Your Health Information Rights
Set forth below is a statement of your rights with respect to your protected
health information and a brief description of how you may exercise these
- Inspect and Copy: You have the right
to inspect and copy medical information that may be used to make decisions
about your care. This means you may inspect and obtain an electronic or paper
copy of protected health information about you that is contained in a
designated record set for as long as we maintain the protected health
information. A “designated record set”
contains medical and billing records and any other records that Fenway Health
uses regarding your care. We ask that
you submit these requests in writing. If you are denied access to medical
information, you may request that the denial be reviewed. The person conducting
the review will not be the person who denied your request. We will comply with
the outcome of the review. Requests for access to and copies of your
medical information must be submitted to Fenway Health in writing. The practice
may charge for copies of the medical record.
- Amend: If you feel that medical information
we have about you is incorrect or incomplete, you may ask us to amend the
information by submitting a request in writing. You have the right to request
an amendment for as long as we keep the information. In certain cases, we may
deny your request for an amendment and if this occurs, you will be notified of
the reason for the denial.
- An Accounting of Disclosures: You have the right
to receive an accounting of certain disclosures we have made, if any, of your
protected health information. This right
does not apply to all disclosures; in particular, it does not apply to
disclosures for purposes necessary to carry out treatment, payment or
healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to
you, you, for a facility directory, to family members or friends involved in
your care, or for notification purposes.
The right to receive this information is subject to additional
exceptions, restrictions and limitations.
Fenway Health will provide the first accounting to you in any 12-month
period without charge. We ask that you submit these requests in writing.
- 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. For example, you could ask that we not use or
disclose information about a procedure that you had. We ask that you
submit these requests in writing.
We are not required to agree to your request. If we do
agree, we will comply with your request unless the information is needed to
provide you with emergency treatment.
You have the ability to restrict your protected health
information from payer disclosure when you pay for services yourself instead of
having charges filed with an insurance carrier.
- 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. We will agree to the request to the extent that it is
reasonable for us to do so. For example, you can ask that we use an alternative
address for billing purposes. We ask that you submit these requests in writing.
- 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. To exercise any of your rights, please obtain the required
forms from the Privacy Officer and submit your request in writing.
Record Retention & Destruction Policy
accordance with Massachusetts General Law c.111, §70 Fenway Health maintains
health records for a period of 20 years after the discharge or the final
treatment of the patient to whom it relates. Following this period records may
be destroyed after notifying the Department of Public Health, in accordance
with regulations, that records will be destroyed.
there is an unintended disclosure of your information you will be contacted
with details of this breach. We are also
required to notify the Secretary of Health and Human Services that a breach
occurred, however, your protected health information will not be included in
that initial breach report. If the
unintended disclosure of your information was part of a breach that involved
five hundred or more individuals, we would also be required to notify the
If you believe your privacy rights have been violated; you may file a complaint
with us by calling our Privacy Officer, Frank Bonelli at 617.927.6191 or by
contacting the Secretary of the Federal Department of Health and Human
Services. All complaints must be also submitted in writing. You will not
be penalized for filing a complaint.
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, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about you for
the reasons covered by your written authorization. However, we are unable to
take back any disclosures we have already made with your permission and we are
required to retain our records of the care that we provided to you.
Privacy Officer: Frank Bonelli
Telephone Number: 617.927.6191
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