Notice of Privacy Practices

• Appointment Reminders. We may use and disclose your protected health information to contact you as a reminder that you have an appointment for treatment or medical care.
• Treatment Alternatives. We may use and disclose your protected health 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 your protected health information to tell you about health-related benefits or services we provide that may be of interest to you.
• Fundraising Activities. We may use demographic information about you, such as name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of services, department of services, treating physician or information regarding outcome, to contact you in an effort to raise money for Valley Health System. We may disclose certain information to The Valley Hospital Foundation so that the Foundation may also contact you regarding these fundraising efforts. You are free to opt-out of fundraising solicitation and your decision will have no impact on your treatment or payment for services. If you do not want to be contacted for fundraising efforts, you must notify the Foundation at 201-291-6300 or by email at [email protected]. You may also opt-out of these communications by contacting the Foundation in writing at The Valley Hospital Foundation, 4 Valley Health Plaza, Paramus, NJ 07652.
• Hospital Directory. We are permitted to include certain limited information about you in The Valley Hospital's patient directory if you are admitted to the emergency department, outpatient, or inpatient department at The Valley Hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. We will give you an opportunity to object to having this information included in The Valley Hospital patient directory. If you do not object, this directory information, except for your religious affiliation, may be released to family, friends and others who call or come to the hospital and ask for you by name or to entities assisting with disaster relief efforts, as noted in the bullet below, so that family, friends and others can locate you. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi. The hospital patient directory allows your family, friends and clergy to locate and visit you during your stay at The Valley Hospital and generally know how you are doing.
• Individuals Involved in Your Care or Payment for Your Care. We are permitted to release protected health information about you to a family member or other individual 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 are being treated by Valley Health System. In addition, we may disclose protected health information about you for disaster relief purposes, such as to a public or private entity helping with disaster relief efforts so that your family can be notified about your condition, status and location. We will give you an opportunity to object to these disclosures.
• Research. Under certain circumstances, we may use and disclose protected health 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' needs for privacy of their medical information. Before we use or disclose your protected health information for research, the project will have been approved through this research approval process. We may, however, disclose 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 information they review does not leave Valley Health System.
• As Required By Law. We will use and disclose protected health information about you when required to do so by federal, state or local law or in response to a court order.
• To Avert a Serious Threat to Health or Safety. We may use and disclose protected health 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 be to someone able to help prevent the threat, and as otherwise permitted by applicable law.
• Business Associates. We may disclose protected health information about you to our vendors and contractors (our "business associates") that perform functions on our behalf or provide us with services, if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not permitted to use or disclose any information other than as specified in our contract or as otherwise permitted by federal, state or local law.

IV. SPECIAL SITUATIONS INVOLVING YOUR PROTECTED HEALTH INFORMATION.

• Organ and Tissue Donation. If you are or may be an organ donor, we may release your protected health 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 your protected health information as required by military command authorities. We may also release such information about foreign military personnel to the appropriate foreign military authority.
• Workers' Compensation. We may release your protected health information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health. We may disclose your protected health information for public health activities. These activities generally include the following:
  • 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 who 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 your protected health 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 healthcare 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 your protected health information in response to a court or administrative order. We may also disclose such 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, or pursuant to your authorization.
• Law Enforcement. We may release certain limited information about you if asked to do so by a law enforcement official, such as:
  • in response to a 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 agreement;
  • about a death we believe may be the result  of criminal conduct;
  • about criminal conduct on our premises; and
  • 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 certain limited protected health information about you 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 such information about patients to funeral directors as necessary to carry out their duties.
• National Security and Intelligence Activities. We may release your protected health information 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 your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
• Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with healthcare; (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.

V. SENSITIVE INFORMATION.

Certain state or federal laws may place more stringent requirements on the disclosure of your protected health information, which may be considered "Sensitive" and subject to special protections under applicable law, including, but not limited to HIV/AIDS, Genetic, Sexually Transmitted Diseases and Tuberculosis information, information related to emancipated care received by a minor, Reproductive Health Care Services, as well as Drug/Alcohol and Mental Health/Behavioral information originating from certain licensed facilities.

We generally may use and disclose your protected health information, which contains Sensitive Information, as permitted by this Notice. Some examples include: (i) we may use and disclose your Genetic information, Drug/Alcohol Metal Health/Behavioral information, including psychotherapy progress notes, or information regarding a Sexually Transmitted Disease as related to treatment, payment or healthcare operations activities described in this Notice, including through one or more HIEs; (ii) We may use and disclose your HIV/AIDS related information to qualified personnel directly involved in your treatment or medical education, including through one or more HIEs, and for other purposes described in this Notice where authorized by law; and (iii) We may use and disclose Reproductive Health Care Services communications or information (such as medical, surgical, counseling, or referral services relating to the human reproductive system, including but not limited to, services relating to pregnancy, contraception, or termination of pregnancy) as related to treatment, payment or healthcare operations activities described by this Notice, including through one or more HIEs, and for other purposes authorized by law.

Where applicable law requires us to obtain a written authorization prior to using or disclosing Sensitive Information for a particular purpose described in this Notice, we will obtain such authorization from you before making such use or disclosure. For example, we will obtain your explicit consent in writing to disclose Reproductive Health Care Services information in any civil action or proceeding preliminary thereto or in any probate, legislative or administrative proceeding unless an exception applies under applicable law, and, you have a right to withhold such written consent. We may also obtain your consent, in the event you are a minor, in certain circumstances prior to disclosing to your parents, information relating to emancipated care you have received.

VI. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding protected health information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care where it is maintained by us in one or more designated record sets. Usually, this includes medical and billing records but does not include psychotherapy process notes. If we maintain such information electronically, you are also entitled to obtain such information in a reasonable electronic form and format (i.e., PDFs on a CD). To inspect and copy such information that may be used to make decisions about you, you must submit your request in writing. For medical records from The Valley Hospital, please write to the Health Information Management Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For medical records from Valley Medical Group, please write to the Privacy Officer, Valley Medical Group, 223 North Van Dien Avenue, Ridgewood, NJ 07450. For medical records from Valley Home Care, please write to the Director of Quality, Valley Home Care, 223 North Van Dien Avenue, Ridgewood, NJ 07450. If you request a copy of the information, we may charge a reasonable cost-based fee for 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 your protected health information, you may request, in writing, that the denial be reviewed. Another licensed healthcare professional chosen by Valley Health System 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.
  • Parents and guardians may not have access to all of the information concerning a minor patient's care or treatment. For example, records related to emancipated care or treatment, which you may have received as a minor, such as related to pregnancy, sexually transmitted disease or certain mental health information, may not be made available to your parent or guardian without your consent unless state laws would authorize us to make such information available to your parent or guardian.

  Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to include additional information or amend your medical record. You have the right to request an amendment for as long as all the information, both old and new, is kept by or for Valley Health System. To request an amendment, your request must be made in writing and submitted to the Privacy Officer, Valley Health System, 223 North Van Dien Avenue, Ridgewood, NJ 07450. 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 information which you would be permitted to inspect and copy;
  • is accurate and complete.