Effective Date: April 14, 2003
NOTICE OF PRIVACY
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 the Privacy
Officer at General Surgery Practice of Northern New Jersey, LLC,
140 Grand Avenue, Englewood NJ 07631
WHO WILL FOLLOW THIS NOTICE:
This notice describes General Surgery Practice of Northern New Jersey,
LLC (our "Practice") practices and
> All physicians and staff of our Practice
> Any student engaged in an extern ship program through an agreement with
our Practice to do so.
> Our Practice follows the terms of this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is
personal. We are committed to protecting medical information about you. We
create a record of the care and services you receive at our Practice. We
need this record to provide you with quality care and to comply with
certain legal requirements. This notice applies to all of the records of
your care generated by our Practice.
This notice will tell you about the ways in which we may use and disclose
medical information about you. We also describe your rights and certain
obligations we have regarding the use and disclosure of medical
We are required by law to:
make sure that medical information
that identifies you is kept private;
give you this notice of our legal
duties and privacy practices concerning medical information about you;
follow the terms of the notice
that is currently in effect.
Notice of Privacy Practices
HOW WE MAY USE AND DISCLOSE
MEDICAL INFORMATION ABOUT YOU.
We use and disclose medical information in many ways. For each category of
uses or disclosures we will explain what we mean and try to give some
examples. Not every use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose information
will fall within one of the categories.
> 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, nursing and medical
students, or hospital personnel who are involved in taking care of you.
For example, a doctor treating you for a broken leg may need to know if
you have diabetes because diabetes may slow the healing process. In
addition, the doctor may need to tell the dietitian if you have diabetes
so that we can arrange for nutritional counseling. We also may share
medical information about you in order to coordinate the different things
you need, such as prescriptions, lab work and x-rays. We also may disclose
medical information about you to people who may be involved in your
medical care such as family members, clergy, rehabilitation centers, etc.
> For Payment. We may use and disclose medical information
about you so that the treatment and services you receive at our Practice
may be billed for and payment may be collected from you or on your behalf
from an insurance company or a third party. For example, we may need to
give your health plan information about x-rays that you received at our
Practice so your health plan will pay us or reimburse you for those
services. We may also tell your health plan about a treatment you are
going to receive to obtain prior approval or to determine whether your
plan will cover the treatment.
> For Health Care Operations. We may use and disclose
medical information about you for our Practice's operations. These uses
and disclosures are necessary to run our organization and make sure that
all of our patients receive quality care. For example, we may use medical
information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical
information about many our Practice patients to decide what additional
services our Practice should offer, what services are not needed, and
whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, nursing and medical students,
and other personnel for review and learning purposes. We may also combine
the medical information we have with medical information from other
similar organizations 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 may use it to study health care and health care delivery without
learning who the specific patients are.
> Appointment Reminders. We may use and disclose
medical information to contact you as a reminder that you have an
appointment for treatment or medical care at our Practice.
> 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.
> Individuals Involved in Your Care or Payment for Your Care.
We may release medical information about you to a friend or family member
who is 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 have been seen in our office. In
addition, we may disclose medical information about you to a friend or
family member should an emergent situation arise while you are at our
> Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes. For example,
a research project may involve comparing the health and recovery of all
patients who received one medication to those who received another, for
the same condition. All research projects, however, are subject to a
special approval process. This process evaluates a proposed research
project and its use of medical information, trying to balance the research
needs with patients' need for privacy of their medical information. Before
we use or disclose medical information for research, the project will have
been approved through this research approval process, but we may, however,
disclose medical information about you to people preparing to conduct a
research project, for example, to help them look for patients with
specific medical needs, so long as the medical information they review
does not leave our organization. We will always ask for your specific
permission if the researcher will have access to your name, address or
other information that reveals who you are, or will be involved in your
care our Practice.
> As Required By Law. We will disclose medical 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 medical 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
> Organ and Tissue Donation.
If you are an organ donor, we may release medical information to
organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to facilitate
organ or tissue donation and transplantation.
> Military and Veterans. If you are a member of the armed
forces, we may release medical information about you as required by
military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military
> Workers' Compensation. We may release medical 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 medical 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 medical information to a health oversight agency for
activities authorized by law. These oversight activities include, for
example, audits, investigations, inspections, and licensure. These
activities are necessary for the government to monitor the health care
system, government programs, and compliance with civil rights laws.
> Lawsuits and Disputes. If you are involved in a lawsuit or
a dispute, we may disclose medical information about you in response to a
court or administrative order. We may also disclose medical information
about you in response to a subpoena, discovery request, or other lawful
process by someone else involved in the dispute, but only if efforts have
been made to tell you about the request or to obtain an order protecting
the information requested.
> Law Enforcement. We may release medical 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;
About the victim of a crime if,
under certain limited circumstances, we are unable to obtain the person's
About a death we believe may be the
result of criminal conduct;
About criminal conduct at the
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. Medical Examiners
and Funeral Directors. We may release medical information to a
coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We may also
release medical information about patients to funeral directors as
necessary to carry out their duties.
> National Security and Intelligence Activities. We may
release medical information about you to authorized federal officials for
intelligence, counterintelligence, and other national security activities
authorized by law.
> Protective Services for the President and Others. We may
disclose medical information about you to authorized federal officials so
they may provide protection to the President, other authorized persons or
foreign heads of state or conduct special investigations.
> Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or
law enforcement official. This release would be necessary: (1) for the
institution to provide you with health care; (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 MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain
> Right to Inspect and Copy. You have the right to inspect
and copy medical information that may be used to make decisions about your
care. Usually, this includes medical and billing records, but does not
include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions
about you, you must submit your request in writing to our Privacy Officer.
If you request a copy of the information, we may charge a fee for the
costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information, you may
request, in writing, that the denial be reviewed. Another licensed health
care professional chosen by our Practice will review your request and the
denial. The person conducting the review will not be the person who
previously denied your request.
We will comply with the outcome of the review.
> Right to Amend. If you feel that medical information we
have about you is incorrect or incomplete, you may ask us to include
additional information in your medical record. You have the right to
request an amendment for as long as all of the information, both old and
new, is kept by or for our Practice.
To request an amendment, your request must be made in writing and
submitted to our Privacy Officer. In addition, you must provide a reason
that supports your request.
We may deny your request for an amendment if it is not in writing or 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 medical
information kept by or for our Practice;
Is not part of the information which
you would be permitted to inspect and copy; or
Is accurate and complete.
> Right to an Accounting of
Disclosures. You have the right to request an "accounting of
disclosures." This is a list of the disclosures we made of medical
information about you, excluding disclosures for the purpose of treatment,
payment and healthcare operations.
To request this list or accounting of disclosures, you must submit your
request in writing to the Office Manager. Your request must state a time
period, which may not be longer than six years and may not include dates
before April 14, 2003. Your request should indicate in what form you
want the list (for example, on paper, electronically). The first list 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 involved and you may choose to withdraw or modify your
request at that time before any costs are incurred.
> Right to 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 surgery you had.
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
To request restrictions, you must make your request in writing to our
Privacy Officer. In your request, you must tell us (1) what information
you want to limit; (2) whether you want to limit our use, disclosure or
both; and (3) to whom you want the limits to apply, for example,
disclosures to your spouse.
> Right to 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. For example, you can ask that we
only contact you at work or by mail.
To request confidential communications, you must make your request in
writing to our Privacy Officer. We will not ask you the reason for your
request. We will accommodate all reasonable requests. Your request must
tell us how or where you wish to be contacted. If you do not tell us how
or where you wish to be contacted, we do not have to follow your request.
> Right to 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. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our web site, www.NJSurgery.com
To obtain a paper copy of this notice, ask any our office staff or our
Privacy Officer or you may write to our Practice at General Surgery
Practice of Northern New Jersey, LLC, 140 Grand Avenue, Englewood
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 medical
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
office. The notice will contain on the first page, in the top right-hand
corner, the effective date. In addition, each time you are seen for
treatment or health care services at our office, we will offer you a copy
of the current notice in effect.
If you believe your privacy rights have been violated, you may file a
complaint with our practice or with the Secretary of the Department of
Health and Human Services at the Office Of Civil Rights, U.S. Department
of Health and Human Services, Jacob Javits Federal Building, 26 Federal
Plaza, Suite 3312, New York, New York 10278. To file a complaint with our
Practice, please write to the Privacy Officer at General Surgery
Practice of Northern New Jersey, LLC, 140 Grand Avenue, Englewood
all complaints must be 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. 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 our records of the care that we provided to you.