THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

Each time you visit Catholic Charities, Diocese of Metuchen, physicians and other healthcare providers make a record of your visit. Typically, this record contains your symptoms, notes about counseling, observations of staff, examinations, test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health, clinical or medical record, serves as a:

• Basis for planning your care and treatment
• Means of communication among the many professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided
• A tool in educating heath professionals
• A source of information for public health officials charged with improving the health of the nation
• A source of data for facility planning
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

• Ensure its accuracy
• Better understand who, what, when, where, and why others may access your health information
• Make more informed decisions when authorizing disclosure to others

Your Health Information Rights

Although your health record is the physical property of Catholic Charities, Diocese of Metuchen, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information
• Obtain a paper copy of this notice
• Inspect and obtain a copy of your record, with limited exceptions
• Amend your record, with limited exceptions
• Obtain an accounting of disclosures of your health information to third parties
• Request communications of your health information by alternative means or at alternative locations
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken

Our Responsibilities

Catholic Charities, Diocese of Metuchen, is required to:

• Maintain the privacy of your health information
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact the Director of Compliance at (732) 324-8200. If you believe your privacy rights have been violated, you can file a complaint with the Director of Compliance or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment. For example: Information obtained by a clinician, nurse, physician, or other member of your service team will be recorded in your record and used to determine the course of services that should work best for you. Your provider will document in your record his or her expectations of the members of your service team. Members of your service team will then record the actions they took and their observations. In that way, the provider will know how you are responding to treatment. Your health information may also be shared with other programs within Catholic Charities, Diocese of Metuchen, if necessary for treatment.

We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations. For example: Members of the medical and clinical staff, the compliance or performance improvement manager, supervisors, directors or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Permitted or Required Uses and Disclosures

Business associates: There are some services provided in our organization through contacts with business associates. Examples include certain laboratory tests and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and 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.
Notification: In an emergency, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with family: With your authorization, health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to drugs, food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law, such as reporting child abuse or neglect, or in response to a valid subpoena.
Funding Sources: We may disclose health information to funding sources and health oversight agencies, such as the Division of Youth and Family Services, Division of Mental Health Services, Division of Health and Senior Services to conduct audit and evaluation activities.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Effective Date: January 23, 2003.

I acknowledge that I have received and understand this Notice. Any questions that I have concerning the use and disclosure of my health information have been answered.

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