HIPAA Privacy Rights
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review
Effective Date: September 23, 2013
If you have any questions about this notice, please contact the Hospital’s
Saint Francis Healthcare is required by the Health Insurance Portability
and Accountability Act of 1996, and the Health Information Technology
for Economic and Clinical Health Act (found in Title XIII of the American
Recovery and Reinvestment Act of 2009) (collectively referred to as “HIPAA”),
as amended from time to time, to maintain the privacy of individually
identifiable patient health information (this information is “protected
health information” and is referred to herein as “PHI”).
We are also required to provide patients with a Notice of Privacy Practices
regarding PHI. We will only use or disclose your PHI as permitted or required
by applicable state law. This Notice applies to your PHI in our possession
including the medical records generated by us.
Saint Francis Healthcare understands that your health information is highly
personal, and we are committed to safeguarding your privacy. Please read
this Notice of Privacy Practices thoroughly. It describes how we will
use and disclose your PHI.
This Notice applies to the delivery of health care by Saint Francis Healthcare
employees, staff and its medical staff in the main hospital, outpatient
departments, clinics, physician practices, Saint Francis Foundation, Saint
Francis Life and Saint Francis Home Health. This Notice also applies to
the utilization review and quality assessment activities of Trinity Health
and Saint Francis Healthcare as a member of Trinity Health], a Catholic
health care system with facilities located in multiple states throughout
the United States.
Permitted Use or Disclosure
A. Treatment: Saint Francis Healthcare will use and disclose your PHI to provide, coordinate,
or manage your health care and related services to carry out treatment
functions. The following are examples of how Saint Francis Healthcare
will use and/or disclose your PHI:
- To your attending physician, consulting physician(s), and other health
care providers who have a legitimate need for such information in your
care and continued treatment.
- To coordinate your treatment (e.g., appointment scheduling) with us and
other health care providers such as name, address, employment, insurance
- To contact you as a reminder that you have an appointment for treatment
or medical care at our facilities.
- To provide you with information about treatment alternatives or other health-related
benefits or services.
- If you are an inmate of a correctional institution or under the custody
of a law enforcement officer, Saint Francis Healthcare will disclose your
PHI to the correctional institution or law enforcement official.
B. Payment: Saint Francis Healthcare will use and disclose PHI about you for payment
purposes. The following are examples of how Saint Francis Healthcare will
use and/or disclose your PHI:
- To an insurance company, third party payer, third party administrator,
health plan or other health care provider (or their duly authorized representatives)
for payment purposes such as determining coverage, eligibility, pre-approval
/ authorization for treatment, billing, claims management, reimbursement
- To collection agencies and other subcontractors engaged in obtaining payment for care.
C. Health Care Operations: Saint Francis Healthcare will use and disclose your PHI for health care
operations purposes. The following are examples of how Saint Francis Healthcare
will use and/or disclose your PHI:
- For case management, quality assurance, utilization, accounting, auditing,
population based activities relating to improving health or reducing health
care costs, education, accreditation, licensing and credentialing activities
of Saint Francis Healthcare.
- To consultants, accountants, auditors, attorneys, transcription companies,
information technology providers, etc.
D. Other Uses and Disclosures: As part of treatment, payment and health care operations, Saint Francis
Healthcare may also use your PHI for the following purposes:
- Fundraising Activities: Saint Francis Healthcare will use and may also
disclose some of your PHI to a related foundation for certain fundraising
activities. For example, Saint Francis Healthcare may disclose your demographic
information, your treatment dates of service, treating physician information,
department of service and outcomes information to the foundation who may
ask you for a monetary donation. Any fundraising communication sent to
you will let you know how you can exercise your right to opt-out of receiving
similar communications in the future.
- Medical Research: Saint Francis Healthcare will use and disclose your PHI
without your authorization to medical researchers who request it for approved
medical research projects. Researchers are required to safeguard all PHI
- Information and Health Promotion Activities: Saint Francis Healthcare will
use and disclose some of your PHI for certain health promotion activities.
For example, your name and address will be used to send you general newsletter
or specific information based on your own health concerns.
E. More Stringent State and Federal Laws: The State law of Delaware is more stringent than HIPAA in several areas.
Certain federal laws also are more stringent than HIPAA. Saint Francis
Healthcare will continue to abide by these more stringent state and federal laws.
- More Stringent Federal Laws: The federal laws include applicable internet
privacy laws, such as the Children’s Online Privacy Protection Act
and the federal laws and regulations governing the confidentiality of
health information regarding substance abuse treatment.
- More Stringent State Laws: State law is more stringent when the individual
is entitled to greater access to records than under HIPAA. State law also
is more restrictive when the records are more protected from disclosure
by state law than under HIPAA. In cases where Saint Francis Healthcare
provides treatment to a patient who resides in a neighboring state, Saint
Francis Healthcare will abide by the more stringent applicable state law.
F. Health Information Exchange: Saint Francis Healthcare shares your health records electronically with
Delaware Health Information Network for the purpose of improving the overall
quality of health care services provided to you (e.g., avoiding unnecessary
duplicate testing). The electronic health records will include sensitive
diagnoses such as HIV/AIDS, sexually transmitted diseases, genetic information,
and mental health substance abuse, etc. The HIE is functioning as our
business associate and, in acting on our behalf, the HIE will transmit,
maintain and store your PHI for treatment, payment and health care operation
purposes. The HIE has a duty to implement administrative, physical and
technical safeguards that reasonably and appropriately protect the confidentiality
and integrity of your medical information.You have the right to “opt-out” and prevent your health information
from being sent to the Delaware Health Information Network by completing
and submitting an “Opt-Out” form directly to the DHIN.
If you have any questions, please contact DHIN
Call DHIN toll free: 1.888.933.3446
Visit the DHIN website:
Permitted Use or Disclosure with an Opportunity for You to Agree or Object
A. Family/Friends: Saint Francis Healthcare will disclose PHI about you to a friend or family
member who is involved in or paying for your medical care. You have a
right to request that your PHI not be shared with some or all of your
family or friends. In addition, Saint Francis Healthcare will disclose
PHI about you to an agency assisting in disaster relief efforts so that
your family can be notified about your condition, status, and location.
B. Saint Francis Healthcare – Facility Directory: Saint Francis Healthcare will include certain information about you in
facility directory while you are a hospital patient at Saint Francis Healthcare
This information will include your name, location in Saint Francis Healthcare,
your general condition (e.g., fair, stable, critical, etc.) and your religious
affiliation. The directory information, except your religious affiliation,
will be disclosed to people who ask for you by name. You have the right
to request that your name not be included in Saint Francis Healthcare’s
directory. If you request to opt-out of the facility directory, we cannot
inform visitors of your presence, location, or general condition.
C. Spiritual Care: Directory information, including your religious affiliation, will be given
to a member of the clergy, even if they do not ask for you by name. Spiritual
care providers are members of the health care team at Saint Francis Healthcare
and may be consulted upon regarding your care. You have the right to request
that your name not be given to any member of the clergy.
D. Media Reports: Saint Francis Healthcare will release facility directory information to
the media (excluding religious affiliation) if the media requests information
about you using your name and after we have given you an opportunity to
agree or object.
Use or Disclosure Requiring Your Authorization
A. Marketing: Subject to certain limited exceptions, your written authorization is
required in cases where Saint Francis Healthcare receives any direct or
indirect financial remuneration in exchange for making the communication
to you which encourages you to purchase a product or service or for a
disclosure to a third party who wants to market their products or services to you.
B. Research: Saint Francis Healthcare will obtain your written authorization to use
or disclose your PHI for research purposes when required by HIPAA.
C. Psychotherapy Notes: Most uses and disclosures of psychotherapy notes require your written
D. Sale of PHI: Subject to certain limited exceptions, disclosures that constitute a sale
of PHI require your written authorization.
E. Other Uses and Disclosures: Any other uses or disclosures of PHI that are not described in this Notice
of Privacy Practices require your written authorization. Written authorizations
will let you know why we are using your PHI. You have the right to revoke
an authorization at any time.
Use or Disclosure Permitted or Required by Public Policy or Law without
A. Law Enforcement Purposes: Saint Francis Healthcare will disclose your PHI for law enforcement purposes
as required by law, such as identifying a criminal suspect or a missing
person, or providing information about a crime victim or criminal conduct.
B. Required by Law: Saint Francis Healthcare will disclose PHI about you when required by
federal, state or local law. Examples include disclosures in response
to a court order / subpoena, mandatory state reporting (e.g., gunshot
wounds, victims of child abuse or neglect), or information necessary to
comply with other laws such as workers’ compensation or similar
laws. Saint Francis Healthcare will report drug diversion and information
related to fraudulent prescription activity to law enforcement and regulatory agencies.
C. Public Health Oversight or Safety: The Saint Francis Healthcare will use and disclose PHI to avert a serious
threat to the health and safety of a person or the public. Examples include
disclosures of PHI to state investigators regarding quality of care or
to public health agencies regarding immunizations, communicable diseases,
etc. Saint Francis Healthcare will use and disclose PHI for activities
related to the quality, safety or effectiveness of FDA regulated products
or activities, including collecting and reporting adverse events, tracking
and facilitating in product recalls, etc.
D. Coroners, Medical Examiners, Funeral Directors: Saint Francis Healthcare will disclose your PHI to a coroner or medical
examiner. For example, this will be necessary to identify a deceased person
or to determine a cause of death. Saint Francis Healthcare may also disclose
your medical information to funeral directors as necessary to carry out
E. Organ Procurement: Saint Francis Healthcare will disclose PHI to an organ procurement organization
or entity for organ, eye or tissue donation purposes.
F. Specialized Government Functions: Saint Francis Healthcare will disclose your PHI regarding government functions
such as military, national security and intelligence activities. Saint
Francis Healthcare will use or disclose PHI to the Department of Veterans
Affairs to determine whether you are eligible for certain benefits.
G. Immunizations: Saint Francis Healthcare will disclose proof of immunization to a school
where the state or other similar law requires it prior to admitting a student.
Your Health Information Rights
You have the following individual rights concerning your PHI:
A. Right to Inspect and Copy: Subject to certain limited exceptions, you have the right to access your
PHI and to inspect and copy your PHI as long as we maintain the data.
If Saint Francis Healthcare denies your request for access to your PHI,
Saint Francis Healthcare will notify you in writing with the reason for
the denial. For example, you do not have the right to psychotherapy notes
or to inspect the information which is subject to law prohibiting access.
You may have the right to have this decision reviewed.
You also have the right to request your PHI in electronic format in cases
where Saint Francis Healthcare utilizes electronic health records. You
may also access information via patient portal if made available by Saint
You will be charged a reasonable copying fee in accordance with applicable
federal or state law.
B. Right to Amend: You have the right to amend your PHI for as long as Saint Francis Healthcare
maintains the data. You must make your request for amendment of your PHI
in writing to Saint Francis Healthcare, including your reason to support
the requested amendment.
However, Saint Francis Healthcare will deny your request for amendment if:
- Saint Francis Healthcare did not create the information;
- The information is not part of the designated record set;
- The information would not be available for your inspection (due to its
condition or nature); or
- The information is accurate and complete.
If Saint Francis Healthcare denies your request for changes in your PHI,
Saint Francis Healthcare will notify you in writing with the reason for
the denial. Saint Francis Healthcare will also inform you of your right
to submit a written statement disagreeing with the denial. You may ask
that Saint Francis Healthcare include your request for amendment and the
denial any time that Saint Francis Healthcare subsequently discloses the
information that you wanted changed. Saint Francis Healthcare may prepare
a rebuttal to your statement of disagreement and will provide you with
a copy of that rebuttal.
C. Right to an Accounting: You have a right to receive an accounting of the disclosures of your PHI
that Saint Francis Healthcare has made, except for the following disclosures:
- To carry out treatment, payment or health care operations;
- To you;
- To persons involved in your care;
- For national security or intelligence purposes; or
- To correctional institutions or law enforcement officials.
You must make your request for an accounting of disclosures of your PHI
in writing to Saint Francis Healthcare.
You must include the time period of the accounting, which may not be longer
than 6 years. In any given 12-month period, Saint Francis Healthcare will
provide you with an accounting of the disclosures of your PHI at no charge.
Any additional requests for an accounting within that time period will
be subject to a reasonable fee for preparing the accounting.
D. Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures
of your PHI to carry out treatment, payment or health care operations
functions or to prohibit such disclosure. However, Saint Francis Healthcare
will consider your request but is not required to agree to the requested
E. Right to Request Restrictions to a Health Plan: You have the right to request a restriction on disclosure of your PHI
to a health plan (for purposes of payment or health care operations) in
cases where you paid out of pocket, in full, for the items received or
F. Right to Confidential Communications: You have the right to receive confidential communications of your PHI
by alternative means or at alternative locations. For example, you may
request that Saint Francis Healthcare only contact you at work or by mail.
G. Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice of Privacy Practices,
Breach of Unsecured PHI
If a breach of unsecured PHI affecting you occurs, Saint Francis Healthcare
is required to notify you of the breach.
Sharing and Joint Use of Your Health Information
In the course of providing care to you and in furtherance of Saint Francis
Healthcare’s mission to improve the health of the community, Saint
Francis Healthcare will share your PHI with other organizations as described
below who have agreed to abide by the terms described below:
A. Medical Staff. The medical staff and Saint Francis Healthcare participate together in
an organized health care arrangement to deliver health care to you. Both
Saint Francis Healthcare and medical staff have agreed to abide by the
terms of this Notice with respect to PHI created or received as part of
delivery of health care to you by Saint Francis Healthcare. Physicians
and allied health care professionals who are members of Saint Francis
Healthcare’s medical staff will have access to and use your PHI
for treatment, payment and health care operations purposes related to
your care within Saint Francis Healthcare. Saint Francis Healthcare will
disclose your PHI to the medical staff and allied health professionals
for treatment, payment and health care operations.
B. Membership in Trinity Health. Saint Francis Healthcare and members of Trinity Health participate together
in an organized health care arrangement for utilization review and quality
assessment activities. We have agreed to abide by the terms of this Notice
with respect to PHI created or received as part of utilization review
and quality assessment activities of Trinity Health and its members. Members
of Trinity Health will abide by the terms of their own Notice of Privacy
Practices in using your PHI for treatment, payment or health care operations.
As a part of Trinity Health, a national Catholic health care system, Saint
Francis Healthcare and other hospitals, nursing homes, and health care
providers in Trinity Health share your PHI for utilization review and
quality assessment activities of Trinity Health, the parent company, and
its members. Members of Trinity Health also use your PHI for your treatment,
payment to Saint Francis Healthcare and/or for the health care operations
permitted by HIPAA with respect to our mutual patients.
Please go to Trinity Health’s website for a listing of member organizations at
http://www.trinity-health.org/. Alternatively, you can call Saint Francis Healthcare’s Privacy
Official to request the same.
C. Business Associates. Saint Francis Healthcare will share your PHI with business associates
and their Subcontractors contracted to perform business functions on Saint
Francis Healthcare’s behalf, including Trinity Health which performs
certain business functions for Saint Francis Healthcare.
Changes to this Notice
Saint Francis Healthcare will abide by the terms of the Notice currently
in effect. Saint Francis Healthcare reserves the right to make material
changes to the terms of its Notice and to make the new Notice provisions
effective for all PHI that it maintains. Saint Francis Healthcare will
distribute / provide you with a revised Notice at your first visit following
the revision of the Notice in cases where it makes a material change in
the Notice. You can also ask Saint Francis Healthcare for a current copy
of the Notice at any time.
If you believe your privacy rights have been violated, you may file a complaint
with Saint Francis Healthcare’s Privacy Official or with the Secretary
of the Department of Health and Human Services. All complaints must be
submitted in writing directly to Saint Francis Healthcare’s Privacy
Official. To file a complaint with St. Francis Healthcare Services, contact
the Privacy Officer at St. Francis Hospital, 7th & Clayton Streets,
Wilmington, Delaware, 19805. All complaints must be submitted in writing.
Saint Francis Healthcare assures you that there will be no retaliation
for filing a complaint.
You will not be retaliated against for filing any complaint.
Privacy Official – Questions / Concerns / Additional Information
If you have any questions, concerns, or want further information regarding
the issues covered by this Notice of Privacy Practice or seek additional
information regarding Saint Francis Healthcare’s privacy policies
and procedures, please contact Saint Francis Healthcare’s Integrity
& Compliance Officer at 610.567.6702 or call the Integrity Hotline