Patient Rights

(Effective April 14, 2003)

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.

Member Organizations

This notice applies to the following Steward Health Care organizations and affiliates including their physicians, nurses, and other personnel:

Good Samaritan Medical Center
NORCAP Lodge

As of April 14, 2003, we are required under the Health Insurance Portability and Accountability Act (HIPAA) and currently under Massachusetts law to maintain the privacy of your health information, and to provide you with this Notice of Privacy Rights & Practices.

This document explains in detail how we use your Protected Health Information (PHI), which is any information about you that could identify you, your past, present, or future physical or mental health condition(s). Your acknowledgement of receipt of this document will be required the first time you receive services after April 14, 2003, at one of the Steward Health Care organizations and affiliates listed above.

Examples of how we can use and disclose your information without your authorization include:

Treatment - we keep a record of each visit and/or admission. These records may include your test results, diagnoses, medications or other therapies. These records are used and disclosed to allow doctors, nurses, spiritual care staff, and other health care and clinical staff providers to offer high quality care to meet your needs.
Payment - we maintain a record of, and may use and disclose information related to, services and supplies you receive at each visit and/or admission, so that we can be paid by you, an insurance company, or a third party. We may tell your health plan and other payors about an upcoming treatment or service, which requires their prior approval and authorization.
Health care operations - we use and disclose your medical information to improve the services we provide, to train staff and students, for business management, and for customer service purposes.

Your information may be shared among Steward Health Care organizations, other health care providers, third party payors and our business associates to facilitate treatment, payment or health care operations.

Additional Uses And Disclosures:

I. There are additional times when we are permitted or required to use/disclose medical information without your permission. These circumstances include:

In emergency treatment situations
If required by law
To assist uncommunicative patients
For law enforcement
For reporting child/elder/disabled persons abuse or neglect
For public health activities (tracking diseases or medical devices)
For organ donations
To workers' compensation if you are injured at work
For health oversight activities, such as fraud investigations
To coroners, medical examiners and funeral directors
For certain judicial or administrative proceedings
For government functions, such as national security and intelligence
To a correctional institution if you are an inmate
For research following an appropriate review or waiver of authorization by an institutional review board to ensure protection of information
To avert serious threat to public health or safety

II. We may also use your information without your permission to:

Recommend treatment alternatives
Tell you about health benefits and/or services
Send or call you with appointment reminders
List your name, location and general condition in the patient directory for the duration of your stay
List your religious affiliation in the patient directory provided to clergy for the duration of your stay
To communicate with those involved in your care

Except as otherwise permitted by law, all other uses and disclosures not described above will require your signed authorization. You may revoke any authorization you provide at any time by delivering a written statement directly to the privacy officer, except to the extent that we have already taken action in reliance on your authorization.

III. Please know that federal and state law requires special privacy protections for certain highly confidential information about you including but not limited to:

Psychotherapy notes
Mental health and developmental disabilities services
Alcohol and drug abuse prevention, treatment and referral
HIV/AIDS testing, diagnosis or treatment
Venereal disease(s)
Genetic testing
Child abuse and neglect
Domestic abuse of an adult with a disability
Sexual assault

In order for us to disclose your highly confidential information for a purpose other than those permitted by law, we must obtain your written authorization.

Your Rights

Under HIPAA, you have the right to request in writing:

Restrictions on how we use or disclose your medical information
Confidential communications to an alternate phone or address other than your home
Access to your medical information to review and obtain a copy, subject to federal and state laws (fees may apply)
An amendment to your medical information if you feel you or your health care provider need to make additions or corrections
An accounting of disclosures of your medical information for purposes other than treatment, payment, health care operations or made pursuant to an authorization
A paper copy of this notice even if you have received it electronically
A revocation of any specific authorization obtained in connection with your privacy, such as for marketing and research
While we will consider all requests for privacy restrictions carefully, we are not required to agree to any requested restrictions

Our Responsibilities

We are required by law to maintain the privacy of your medical information, to provide you with this written notice of privacy rights and practices, and to abide by the terms of the notice currently in effect. We reserve the right to change this Notice and our privacy practices and make the new provisions effective for all information we maintain. Revised Notices will be posted in our facilities and offices, and will be available from your direct treatment provider.

For More Information

If you would like further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our privacy officer at the address or phone number below. You may also file written complaints with the director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the privacy officer will provide you with the correct address for the director. We will not retaliate against you if you file a complaint with us or with the director. The Steward Health Care System and its employees are committed to protecting patient privacy.

Good Samaritan Medical Center
Privacy Officer
235 North Pearl Street
Brockton, MA 02301
Phone: 508-427-3100