We are serious about safeguarding the information that our patients have entrusted to us.
Please review this notice to better understand our Privacy Practices that protect your personal health information.
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.
Hallmark Health System, Inc. operates as an affiliated covered entity and under an organized healthcare arrangement under federal law. This Notice applies to our services provided at all of Hallmark Health System, Inc.’s facilities listed on page 2 of this notice and at any other clinical sites owned or operated by Hallmark Health System, Inc. If you have any questions about this notice, please contact Hallmark Health’s Privacy Office at:
Who Has Access to Your Protected Health Information?
The following Hallmark Health organizations will share Protected Health Information (PHI) with each other, as necessary to carry out treatment, payment or healthcare operations:
- Melrose-Wakefield Hospital and Lawrence Memorial Hospital of Medford
- Members of Hallmark Health System, Inc.’s Medical Staff
- Hallmark Health Medical Associates (HHMA)
- Hallmark Health VNA and Hospice, Inc.
- Hallmark Health PHO, Inc.
- Lawrence Memorial Medical Electronic Record, Inc. (LMMER)
- Hallmark Health CHEM Center for Radiation Oncology
- Hallmark Health Healthy Families Program
- Hallmark Health Advantage
- Hallmark Health Hematology and Oncology Clinic
- Hallmark Health Welfare and Flexible Benefits Plans
- Lawrence Memorial/Regis College School of Nursing and Radiography Programs
In addition to those entities listed above, Hallmark Health may share your protected information with other non-Hallmark Health organizations for reasons such as treatment and research. Hallmark Health will not sell your PHI to third parties for any reason unless you have given specific authorization for such sale. The ways in which Hallmark Health uses and shares your health information to non-Hallmark Health organizations and individuals is specified in this Notice.
Hallmark Health System, Inc. and affiliated entities participate in a shared electronic medical record system (EMR) with members of medical staff of Hallmark Health System, Inc. The participants in the shared EMR include doctors employed by Hallmark Health System, Inc. and independent members of our medical staff. These independent physicians and their employees have access to your PHI through the shared EMR for the purposes of treatment, payment, healthcare operations, along with other uses and disclosures that you authorize and uses and disclosures required by law.
This Notice of Privacy Practices does not cover the policies of other providers not employed by Hallmark Health or an affiliated entity. If your personal physician is not an employee of Hallmark Health or an affiliated entity, they may have different policies regarding their use and disclosure of your PHI. This Notice of Privacy Practices only pertains to those entities listed above and the members of their healthcare teams.
Required Uses and Disclosures of Your Health Information – Without Written Authorization
Members of your healthcare team may include physicians, nurses, other clinicians as well as administrative personnel such as billers and schedulers. Depending on the services that you receive, members of your healthcare team may vary. Members of your healthcare team create a record of the care and the services that you receive as a patient. This is necessary not only for regulatory and legal reasons, it is also necessary in order to provide you with safe, high-quality medical care.
Unless otherwise prohibited by Massachusetts or federal law, Hallmark Health may share your protected health information for treatment, payment and healthcare operations without your permission. There are also other instances where we may share your health information without your permission, as explained below.
We may use your health information to provide you with medical treatment or services. For example, information obtained by a healthcare provider, such as a physician, nurse, medical technician or other person providing health services to you, will record information in your record whenever you receive treatment. This information is necessary for healthcare providers to determine the services and treatments you need. We may disclose medical information about you to those who are involved in caring for you at Hallmark Health and to healthcare providers caring for you at other healthcare facilities. We may also disclose your medical information to those who are responsible for maintaining your health after you leave the hospital.
We may use and disclose your health information for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or to a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment. We may not disclose your health information to a third-party payor if (i) you notify Hallmark Health of your request prior to obtaining the service and (ii) you pay for the services in full prior to receiving the services. For example, if you pre-pay in full for a lab test and do not want that result being disclosed to your insurance company AND you notify HHS prior to the lab test being performed, HHS cannot send this result to your insurance company.
For Healthcare Operations
We may use and disclose your health information for operational purposes. These uses and disclosures may be made to internal HHS staff as well as to external “business associates”. Business associates are individuals or firms that provide services on behalf of Hallmark Health and are required to comply with the same laws relating to the privacy and security of your information. For example, your health information may be disclosed to members of the medical staff, risk, compliance, quality improvement personnel, accrediting agencies, lawyers and law firms, accounting firms, and others for the following operational purposes:
- Evaluate the performance of our staff
- Assess the quality of care and outcomes in your cases and similar cases
- Determine how to continually improve the quality and effectiveness of the healthcare we provide
- Monitor use and access to your protected health information
- Provide accreditation for the hospital and/or specific services
- Perform annual audits as required by Hallmark health or by federal or state regulation, requirements or statutes
Hallmark Health may also contact you for the following purposes without prior permission. You have the ability to request restrictions. Hallmark Health is not required to accept all requests for restrictions but will make every attempt to comply with your request.
- Treatment Alternatives: We may use your health information to inform you about treatment options or other health-related benefits offered by our facilities.
- Fundraising: We may use certain PHI to contact you in the future to raise money for HHS. This information may include your name, address, phone number, department of service, treating physician, outcomes, and the dates for which you received treatment/services at our facilities. If you choose not to participate in our fundraising efforts, you may opt-out by contacting Hallmark Health’s Development Office, either by mail (170 Governor’s Avenue, Medford, MA 02155), by email (Funddevelopmentemail@hallmarkhealth.org) or by phone (781-338-7620). All of our fundraising materials will include instructions on how to opt-out of future mailings. You may also send a notice to Hallmark Health’s Development Office if you do not currently receive fundraising communications and wish to do so.
We may use and disclose your health information for other purposes. Hallmark Health is not required to obtain your permission for these disclosures. These include the following:
- Research: We may use or disclose your health information for research purposes after an institutional review board (IRB) has approved the research based upon the research proposal and established protocols to ensure the privacy of your health information.
- As Required by Law: We may use and disclose information about you as required by law. For example, HHS may disclose information for the following purposes:
- Judicial and administrative proceedings (e.g. subpoenas, court orders, etc.)
- To report information related to victims of abuse, neglect or domestic violence
- To assist law enforcement officials in their law enforcement duties
- Public Health: Your health information may be used or disclosed for public health activities such as assisting public health or legal authorities to prevent or control disease, injury or disability.
- Health Oversight Activities: Your health information may be disclosed to the Secretary of the Department of Health & Human Services and other oversight agencies in order to carry out their legal and regulatory requirements and oversight activities.
- Medical Examiners, Coroners and Funeral Directors: Health Information may be disclosed to a medical examiner or coroner in an effort to identify a deceased individual, or determine the cause of death. Health information may also be disclosed to funeral directors to enable them to carry out their duties.
- Organ/Tissue Donation: If you are an organ donor, your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.
- Health and Safety: Your health information may be used or disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.
- Government Functions: Your health information may be used or disclosed for specialized government functions such as national security and intelligence activities, protective services for the President and other federal officials or reporting to various branches of the armed services as permitted by law.
- Workers’ Compensation: Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.
- Immunization: Immunization records may be released to schools when requested by the patient/parent/legal guardian without authorization when state law mandates that schools require immunization records. The request by the patient/parent/legal guardian may be given verbally or in writing.
- Marketing: HIPAA does not consider communications made face-to-face between you and a member of Hallmark Health’s workforce to be considered marketing. In addition, communications made: (i) to describe a health-related product or service that Hallmark Health provides to you; (ii) for your treatment; or (iii) for case management or care coordination, or to direct or recommend alternative treatments, therapies, providers, or settings of care are also not considered marketing under HIPAA. As long as the communication is made within these specifications, your authorization is not necessary. We will obtain your authorization to use or disclose protected health information for any other marketing purpose which includes communications about a product or service that encourages you to purchase or use a product or service except as specified above.
Other Users and Disclosures – Limited, Restricted or Denied
Hallmark Health may use or disclose your health information without your permission for the reasons listed in this section. However, you have the ability to request that the amount and type of information disclosed be limited, restricted or that the use/disclosure not be made at all. Hallmark Health does not have to agree to every request; however, we will review all requests. All requests for restrictions will be reviewed and honored if operationally possible.
- Hospital Facility Directory: During an inpatient stay at the hospital, our facility directory is used to provide your name, location and general condition (good, fair, etc.) for callers or visitors asking for you by name. Religious affiliation is also included in our directory, but will only be disclosed to members of the clergy who are not required to ask for you by name. We may use or disclose limited information about you as described above unless you tell us otherwise. You have the right to opt out of our facility directory or to specify what information we may disclose and to whom.
- Disclosures to Family Members, Friends, Or Others Involved in your Care: Hallmark Health respects an individual’s right to define family in their own manner. Hallmark Health may share relevant health information with a family member or other person close to you if that person is involved in your care or payment for your care. Hallmark Health may share your health information with a family member or other person close to you in order to notify him/her/them of your location, general medical condition or death.
If you are present and are able to make your own decisions, we will share this information with you and will try to obtain your permission before sharing it with your family member or other close person. If it is an emergency situation, we may be unable to obtain your permission but will use our professional judgment and limit the amount of information disclosed. If it is in your best interest, we may share information with those who need to know.
- Disaster Relief and Special Situations: We may use or disclose health 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 Users and Disclosures – Your Authorization is Required Prior to Using or Disclosing Your Health Information
Other Uses: For purposes other than those listed above, Hallmark Health is required to obtain your written permission prior to the use or disclosure. For example, most (but not all) disclosures for marketing purposes require your authorization. In addition, certain information that may be “extra sensitive” may have additional state or federal protections (for example, psychotherapy notes) for which Hallmark Health is required to obtain your written authorization before using or disclosing the information. You may revoke the authorization except to the extent HHS has taken action in reliance on such. If you wish to revoke your authorization, you must do so in writing.
Your Health Information Rights
You have the right to:
- Request a restriction on certain uses and disclosures of your protected health information. However, the organizations included in this joint Notice are not required to agree to requested restrictions.
- Obtain a paper copy our Notice of Privacy Practices upon request.
- Inspect and obtain a copy of your health record.
- Request an amendment to your health record.
- Receive confidential communications regarding your care and treatment and request communications by alternative means (e.g. you may request a provider speak to you in a more private setting).
- Receive an accounting of how your medical information has been disclosed for purposes other than treatment, payment or healthcare operations and those as authorized by you.
Our Obligations Under this Joint Notice
We are required by law to:
- Maintain the privacy of your protected health information.
- Provide you with a Notice of our legal duties and privacy practices with respect to your health information.
- Abide by the terms of this Notice.
- Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed.
- Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.
- Notify you of a breach of your unsecured PHI.
- Inform you of any regulatory changes to this Notice of Privacy Practices.
Revised notices will be posted in our facilities, on our website, and will be made available in hard-copy by your healthcare provider or upon registration.
Questions & Concerns
If you believe your Privacy Rights have been violated, you may file a report with the Chief Privacy Officer. You also have the right to file a complaint with the Department of Health and Human Services. You will not be retaliated against for filing a complaint. If you wish to receive a copy of this notice with a larger font, please contact Hallmark Health’s Chief Privacy Officer and one will be provided to you.