Notice of Privacy Practices
I. Who We Are
This Notice describes the privacy practices of Thomas Jefferson University (TJU), including the clinical operations referred to as Jefferson Health, which includes Thomas Jefferson University Hospitals, Inc. (TJUH, Inc.), Jefferson University Physicians (JUP), Abington Hospital, Abington Lansdale Hospital, Abington Health Physicians, Aria Health, Aria Health Physician Services, Kennedy University Hospital, Inc., Kennedy Medical Group Practice, P.C., and “Jefferson Health”), Magee Rehabilitation Hospital. This list of facilities may change from time to time; you may obtain an updated list of facilities by calling 1-833-391-2547.
Jefferson facilities include all patient care, research, laboratory and administrative space owned or leased by Jefferson and any location where Jefferson employees work. All employees, medical staff, students and other members of the Jefferson community (“we” or “us”) follow the terms of this Notice. Jefferson is required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice.
II. How We May Use & Disclose Health Information – Treatment, Payment & Health Care Operations
Jefferson Health understands that information about you and your health is very personal. Therefore, we strive to protect your privacy. We are required by law to maintain the privacy of our patients’ protected health information (PHI) and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We will only use and disclose your PHI as described in this Notice. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice and to make the new notice provisions effective for all PHI we maintain. This page will be updated with any revised notices.
Unless you expressly indicate to the contrary, you agree to receive such information from us and from the persons and entities with whom we share your PHI by automated means, which may include the use of an automatic telephone dialing system (ATDS), pre-recorded message, artificial voice and/or electronic mail (email).
We may use and disclose your PHI in connection with your treatment and/or other services provided to you – for example, to diagnose and treat you. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services. We may also disclose PHI to other providers (e.g., physicians, nurses, pharmacists and other healthcare facilities involved in your treatment).
We may use and disclose your PHI to obtain payment for services that we provide to you – for example, to request payment from your health insurer and to verify that your health insurer will pay for your health care services.
C. Health Care Operations
We may use and disclose your PHI for our health care operations. These include internal administration and planning, and various activities that improve the quality and cost effectiveness of health care services. For example, we may use your PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may also use PHI to resolve patient problems and complaints.
D. Business Associates
We may contract with certain outside persons or organizations to perform certain services on our behalf, such as auditing, accreditation, legal services, etc. At times, it may be necessary for us to provide your information to one or more of these outside persons or organizations. In such cases, we require these business associates, and any of their subcontractors, to appropriately safeguard the privacy of your information.
Other Health Care Providers
We may also disclose PHI to other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, for example, for emergency ambulance companies to request payment for services in bringing you to the hospital.
E. Health Information Exchanges
We participate in Health Information Exchanges (HIEs) which, through secure connected networks with health care providers who participate in the HIEs, makes it possible for us to electronically share protected health information to coordinate patient care. We may electronically share your medical information through HIEs, among participating HIE members for the purposes of treatment, payment, health care operations, and other authorized purposes, to the extent permitted by law.
You have the right to “opt-out” or to decline participation in any HIE that we participate in. To opt out of an HIE you may use the Request for Restriction of Protected Health Information form (PDF).
III. Other Uses and Disclosures of Your PHI for Which Your Written Authorization is not Required
A. Use or Disclosure for the In-Patient Directory
If you are admitted to a Jefferson hospital facility, we may include your name, room number, general health condition and religious affiliation in our hospital patient directory without obtaining your written authorization, unless you choose to object after reading this notice. Information in the hospital directory (other than religious affiliation) may be disclosed to anyone who asks for you by name, either in person or by telephone. This information, including your religious affiliation, may also be disclosed to members of the clergy.
B. Disclosure to Relatives, Friends and Other Caregivers
We may disclose your PHI to a family member, other relative, friend, or any other person if we:
- Obtain your agreement
- Provide you with the opportunity to object to the disclosure and you do not object
- We reasonably assume that you do not object
If we provide information to any individual(s) listed above, we will release only information that we believe is directly relevant to that person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in the event of an emergency or to notify (or assist in notifying) such persons of your location, general condition or death.
C. Fundraising Communications
We may contact you to request a donation to support important activities of Jefferson. We may disclose to our fundraising staff certain demographic information about you (e.g. your name, address, other contact information, age, gender, and date of birth), dates on which we provided health care to you, department of service information, your treating physician, outcome information, and your health insurance status. You may request to opt-out of receiving fundraising communications.
Jefferson will not condition treatment or billing for those services on your choice of whether to receive fundraising communications.
D. Public Health Activities
We may disclose your PHI for the following public health activities:
- Reporting births or deaths
- Preventing or controlling disease, injury or disability
- Reporting child abuse and neglect to public health or other government authorities authorized by law to receive such reports
- Reporting information about products and services under the jurisdiction of the United States Food and Drug Administration, such as reactions to medications and problems with products
- Alerting a person who may have been exposed to an infectious disease or may be at risk of contracting or spreading a disease or condition
- Notifying people of recalls of products they may be using
- Reporting information to your employer as required by laws addressing work-related illnesses and injuries or workplace medical surveillance
E. Victims of Abuse, Neglect or Domestic Violence
If we reasonably believe, you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect or domestic violence.
F. Health Oversight Activities
We may disclose your PHI to a health oversight agency that is responsible for ensuring compliance with rules of government health programs such as Medicare or Medicaid.
G. Legal Proceedings and Law Enforcement
We may disclose your PHI in response to a court order, subpoena or other lawful process.
H. Deceased Persons
We may disclose PHI of deceased individuals to a coroner, medical examiner or funeral director authorized by law to receive such information.
I. Organ and Tissue Donations
We may disclose your PHI to organizations for purposes of organ and tissue donations, banking and / or transplantation.
When conducting research, in most cases, we will ask for your written authorization before PHI is used. However, we may use or disclose your PHI without your specific authorization if Jefferson’s Institutional Review Board (IRB) has waived the authorization requirement. The IRB is a committee that oversees and approves research involving living humans.
K. Public Safety
We may use or disclose your PHI to prevent or lessen a serious and imminent threat to the safety of a person or the public.
L. Specialized Government Functions
We may release your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances, such as for intelligence, counter- intelligence or national security activities.
M. Workers’ Compensation
We may disclose your PHI as authorized by state law relating to workers compensation or other similar government programs.
If you are or become an inmate of a correctional institution or you are in the custody of a law enforcement official, we may release your PHI to the institution or official if required to provide you with healthcare or to protect the health and safety of others.
O. As Required by Law
We may use and disclose your PHI when required to do so by any other laws not already referenced above.
IV. Uses and Disclosures Requiring Your Specific Written Authorization
For any purpose other than the ones described above, we may use or disclose your PHI only when you give Jefferson your specific written authorization. For instance, you will need to sign an authorization form before we send your PHI to a life insurance company. The following are non-exhaustive examples of other uses or disclosures for which your specific written authorization is required:
We may contact you as part of our marketing activities, as permitted by law. We will obtain your written permission when the uses and disclosures of PHI are for marketing purposes or other activities where we receive remuneration in exchange for disclosing such PHI.
If you do not opt-out at the time you provide your PHI, you consent to Jefferson, its affiliates and business associates contacting you by automated means, which may include an ATDS. Your consent is not a condition of purchase. These messages may also include recurring text message promotions and special offers.
B. Sale of PHI
Should we wish to disclose your PHI in any manner that would constitute a sale of your PHI, we will obtain your written authorization to do so.
C. Highly Confidential Information
Federal and state laws require special privacy protections highly confidential information about you. This includes:
- Psychotherapy notes
- Documentation of mental health and developmental disabilities services
- Information about drug and alcohol abuse, prevention, treatment and referral
- Information relating to HIV/AIDS testing, diagnosis or treatment and other sexually transmitted diseases
- Information involving genetic testing and other genetic-related information
Generally, we must obtain your written authorization to release this type of information. However, there are limited circumstances under the law when this information may be released without your consent. For example, certain sexually transmitted diseases must be reported to the Department of Health.
V. Your Rights Regarding Your Protected Health Information
A. Right to Inspect and Copy Your Health Information
You may request to see and receive paper or electronic copies of your medical and billing records. To do so, please submit a written request to the appropriate Jefferson office or department. You will be charged for copies in accordance with established professional, applicable state and federal guidelines and laws. If you are a parent or legal guardian of a minor, certain portions of the minor’s medical record may be inaccessible to you under the law (e.g., records relating to abortion, contraception and/or family planning services and mental health services) unless the patient him/herself authorizes Jefferson to give you access to this PHI.
Additionally, under limited circumstances defined by law, we may deny you access to a portion of your records.
B. Right to Request Restrictions
You may request additional restrictions on Jefferson’s use and disclosure of your PHI
- For treatment, payment and health care operations
- To individuals (such as family members, or other relatives, close friends or any other person identified by you) involved with your care or with payment related to your care
- To notify or assist in the notification of such individuals regarding your location in the hospital and your general condition
- To your health plan (i.e. third-party insurer or healthcare payor) when the PHI is the result of a healthcare item or service that has been fully paid out of pocket
We are not required to agree to your request, and we may say “no” if it would affect your healthcare or if we reasonably believe the information is accurate as is in your record. If we agree to a restriction, we will state the agreed restrictions in writing and will abide by them, except in emergency situations when the disclosure is needed for purposes of treatment.
If you wish to make a request to restrict the use of your PHI, please complete our Request for Restrictions of Protected Health Information (PDF).
C. Right to Receive Confidential Communications
You may request, and we will accommodate, any reasonable written request from you to receive your PHI by alternative means of communication or at alternative locations. For example, you may instruct us not to contact you by telephone at home, or you may give us a mailing address other than your home for test results.
D. Right to Revoke Your Authorization
You may revoke your authorization, except to the extent that we have already used or disclosed your PHI. A revocation form is available upon request from The Privacy Office, as noted below. This form must be completed by you and returned to The Privacy Office.
E. Right to Correct Your Records
You have the right to request that we correct PHI maintained in your medical or billing records. To do so, you must submit a written request to:
The Privacy Office
834 Chestnut Street, Suite 400
ATTN: Enterprise Chief Privacy Officer
We may say “no” to your request, but we will tell you why in writing within 60 days.
F. Right to Receive An Accounting of Disclosures
You may request a record of certain disclosures of your PHI. Your request may cover any disclosures made in the six years prior to the date of your request. Certain disclosures do not need to be included in this accounting, including those made for treatment, payment and operations purposes.
G. Right to Receive Notification
You have the right to receive written notification from Jefferson in the event of a breach of your unsecured PHI, ie, if there is an unauthorized use or disclosure of your PHI which meets certain criteria under the law.
H. For Further Information; Complaints
If you have a question or wish to file a complaint about related to the privacy of your health care information, please call The Privacy Office at 1-833-391-2547, email us at firstname.lastname@example.org or contact us by mail at:
Jefferson Health – Center City
834 Chestnut Street, Suite 400
Philadelphia, PA 19107
Attention: The Privacy Office
If you wish to remain anonymous, contact the Jefferson Alertline via telephone at 1-833-ONE-CODE (833-663-2633).
Additionally, you may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services located at:
200 Independent Avenue, SW
Washington, DC 20201
VI. Effective Date and Duration of This Notice
A. Effective Date
This notice is effective on April 14, 2003.
B. Date of Revision
This Notice was revised September 23, 2013 and April 28, 2017, January 2019.
C. Right to Change Terms of this Notice
We may change the terms of this Notice at any time. If we change this notice, we will update this page and post the revised notice in appropriate locations around Jefferson. You also may obtain any revised notice by contacting The Privacy Office.
VII. European Union – General Data Protection Regulations
If you are a resident of a European Union Member state, please refer to the EU General Data Protection Regulations.