Privacy of patient information

Policy

Patients at Silver Hill Hospital, Silver Hill New York and associated practices have the right to privacy. Information regarding specific events or contained in the patient's medical record shall be treated as confidential.  Access to patient information is allowed on "a need to know" basis only, accessing the least amount of information necessary to perform one's job duties. Information will be released only with written authorization of the patient, legal guardian, or legally designated representative, and in specific situations as outlined in the HIPAA policies and procedures.

To provide a balance between information sharing and confidentiality, individuals/departments have been identified with specific policies and procedures outlining their access to and the need for patient information and patient identifiable data:

• Health Information Management personnel will have access to all documentation present in the medical record using the minimum necessary concept and according to department policies and procedures.

• Nursing staff, Utilization management, Social Work Department and Transitional Living staff will have access to all pertinent information to allow for optimum assessment, treatment and care of the patient in accordance with hospital or department policies and procedures.

• Medical Staff will have access to all pertinent patient information that will allow them to render optimum treatment to any patient that they are attending, covering or consulting physician in accordance with medical staff by laws and rules and regulations.

• Senior Management (Medical Director, Chief Medical Officer, Deputy Chief Medical Officer, Executive Director of Quality and Experience) team leads and clinical department directors will have access to the medical record using the minimum necessary concept for supervisory and risk management purposes.

• Clerical staff under the business office umbrella will have access to all necessary patient information for appropriate billing, insurance and financial procedures.

• Management of Information System and IT staff will have access to patient information for writing reports and for maintenance of Eclipsys and Open Vista system integrity in accordance with departmental policies and procedures.

• Quality Improvement and Experience staff will have access to all pertinent patient information, both clinical and financial to allow for optimum assessment required in functions under the department umbrella.

• Community Outreach will have access to patient information relating to hospital referrals and continuing care in accordance with departmental policies and procedures.

• Contracted Laboratory employees will have access to patient information relating to laboratory testing to allow for optimum care of patients in accordance with hospital, medical staff and departmental policies and procedures.

Procedure

All Silver Hill Hospital workforce members, such as volunteers, hospital staff members and physicians, having access to information concerning patients or knowledge of the presence of a patient, must hold all information in strict confidence.  This information must not be shared with anyone even fellow employees unless in the performance of ones duties.

Access to patient records is strictly on a "need to know" basis as described above.  Scanning a patient unit or house census in the EHR (electronic health record) or viewing the medical record for "potential" need is not permitted.

Periodic patient record audit trails will be run in the EHR to ascertain if access to the record was appropriate.

External requests for patient information will be directed to the Health Information Management Department.  Disposition of such requests will be in accordance with the hospital's established policy and procedure for Release of Information.

At no time shall staff members, volunteers or others associated with Silver Hill Hospital speak with the news media or others outside the hospital.  All encounters with the news media should be directed to the Director of Strategy at extension 2331.

Joint notice of privacy practices

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please call the Privacy Officer at 203-801-2348.

The effective date of this privacy notice is September 30, 2024.

Who Follows This Notice

This Joint Notice of Privacy Practices (“Notice”) applies to the following entities affiliated with Silver Hill Health, Inc.: Silver Hill Hospital, Inc., Silver Hill New York, Silver Hill Therapeutic Services, LLC (collectively, “Silver Hill Health”).  This Notice describes how Silver Hill Health providers use and disclose personally identifiable medical/health information that we create or process in connection with your treatment (“Protected Health Information”) and applies to all Silver Hill Health employees, contractors, trainees, volunteers, members of our medical staffs and their approved personnel when providing services to you at a Silver Hill Health location, and any other members of the Silver Hill Health workforce who are authorized to use or access your Protected Health Information.

Our Responsibilities to You

At Silver Hill Health, we respect the privacy and confidentiality of your Protected Health Information. This Notice describes how we may use and disclose your Protected Health Information and how you can get access to this information. This Notice applies to uses and disclosures we may make of any of your Protected Health Information, whether created or received by us.

We are required by law to:

1. Maintain the privacy of your Protected Health Information.

2. Give you this Notice of our legal duties and privacy practices regarding your Protected
   Health Information.

3. Follow the terms of this Notice.

How We May Use and Disclose Your Health Information

The following describes the ways we may use and disclose your Protected Health Information. Except for the purposes described below, we will use and disclose Protected Health Information only with your written permission. You may revoke such permission at any time by writing to our Privacy Officer.

1. For Treatment.  We may use and disclose Protected Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Protected Health Information to doctors, nurses, technicians, or other personnel, including people outside of the Silver Hill Health, who are involved in your medical care and need the information to provide you with medical care. We may participate in certain health information exchanges, whereby we may disclose your health information, as permitted by law, to other health care providers for treatment purposes. Laboratory services ordered in connection with your treatment at a Silver Hill Health location are processed and provided by Quest Diagnostics. If you have a patient portal with MyQuest through Quest Diagnostics, your laboratory results from Silver Hill Health will be posted to the patient portal.

2. For Payment.  We may use and disclose Protected Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

3. For Health Care Operations.  We may use and disclose Protected Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive high quality care and to operate and manage our programs and facilities. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. 

4. Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Protected Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Protected Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

5. Individuals Involved in Your Care or Payment for Your Care.  When appropriate, we may share Protected Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend.  We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. 

6. Research.  Under certain circumstances, we may use and disclose Protected Health Information for research.  For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition.  Before we use or disclose Protected Health Information for research, the project will go through a special approval process.  Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Protected Health Information.

Special Situations

As Required by Law We will disclose Health Information when required to do so by international, federal, state, or local law.

1. To Avert a Serious Threat to Health or Safety.  We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent or mitigate the threat. 

2. Business Associates & Qualified Service Organizations.  We may disclose Protected Health Information to our business associates or qualified service organizations 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 and qualified service organizations are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

3. Organ and Tissue Donation.  If you are an organ donor, we may use or release Protected Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking, or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation and transplantation.

4. Military and Veterans.  If you are a member of the armed forces, we may release Protected Health Information as required by military command authorities. We also may release Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.

5. Workers’ Compensation.  We may release Protected Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

6. Public Health Risks.   We may disclose Protected Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and 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.

7. Health Oversight Activities.  We may disclose 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 health care system, government programs, and compliance with civil rights laws.

8. Data Breach Notification Purposes.   We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your Protected Health Information to you and/or applicable regulatory agencies as required by law.

9. Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in response to a court or administrative order. We also may disclose Protected Health Information 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. 

10. Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is:
    1:   in response to a court order, subpoena, warrant, summons, or similar process;
    2:   limited information to identify or locate a suspect, fugitive, material witness, or missing person;
    3:   about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement;
    4:   about a death we believe may be the result of criminal conduct;
    5:   about criminal conduct on our premises; and
    6:   in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. 

See “Special Regulations Regarding Disclosure of Psychiatric, Substance Use Disorder, and HIV-Related Information” below for exceptions related to substance use records.

1. Coroners, Medical Examiners, and Funeral Directors.  We may release Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Protected Health Information to funeral directors as necessary for their duties. 

2. National Security and Intelligence Activities. We may release Protected Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 

3. Protective Services for the President and Others.  We may disclose Protected Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.

4. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Protected Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety, or the health and safety of others; or (3) the safety and security of the correctional institution.

5. Fundraising Activities. We may use limited Protected Health Information such as your name, address, phone number, email address and the dates you received treatment or services, to contact you in an effort to raise money for Silver Hill Health. You have the right to opt-out of receiving fundraising communications.  Any fundraising communication sent to you will contain information on how you can opt-out of receiving similar communications in the future.

Written authorization is required by you, or your legal guardian, or legally designated representative for all other uses or disclosures.

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. However, disclosures that we made in reliance on your authorization before you revoked it will not be affected by the revocation.  

Your Rights

You have the following rights regarding the Protected Health Information we have about you:

1. Right to Access. You have a right to inspect and copy Protected Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Protected Health Information, you must make your request, in writing, to the Health Information Management Department Silver Hill Health, 208 Valley Road, New Canaan, Connecticut 06840. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act, or any other state of federal needs-based benefit program.
   We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

2. Right to an Electronic Copy of Electronic Medical Records.  If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

3. Right to Get Notice of a Breach.  You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

4. Right to Amend your Record.   If you believe the Protected Health Information, we have in your record is incorrect or incomplete, you have the right to request that we correct the records by submitting a request in writing to the Health Information Management Department Silver Hill Hospital, 208 Valley Road, New Canaan, Connecticut 06840. We may deny your request to amend a record if the information is not maintained by us; or if it is determined that your record is accurate.

5. Right to an Accounting of Disclosures.  You have the right to request a list of certain disclosures we made of Protected Health Information for purposes other than treatment, payment, and health care operations, or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the Health Information Management Department, Silver Hill Hospital, 208 Valley Road, New Canaan, Connecticut 06840. 

6. Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Protected Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Health Information Management Department Silver Hill Hospital, 208 Valley Road, New Canaan, Connecticut 06840. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan as described in more detail below (See #7 “Out-of-Pocket Payments”). If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

7. Out-of-Pocket-Payments.  If you paid out-of-pocket in full for a specific item or service and you have requested that we not bill your health plan, you have the right to ask that your Protected Health Information, with respect to that item or service, not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

8. Right to Request Confidential Communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to the Health Information Management Department, Silver Hill Hospital, 208 Valley Road, New Canaan, Connecticut 06840. Your request must specify how or where you wish to be contacted.  We will accommodate reasonable requests.

9. Right to a Paper Copy of This Notice.  You have the right to a paper copy of this Notice. You may ask us to provide you with a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.silverhillhospital.org. To obtain a paper copy of this notice, contact the Health Information Management Department, Silver Hill Hospital, 208 Valley Road, New Canaan, Connecticut 06840.

Special Regulations Regarding Disclosure of Psychiatric, Substance Use Disorder, and HIV-Related Information

For disclosures concerning health information relating to care for psychiatric conditions, substance use disorders, or HIV-related information, special restrictions may apply.  For example, we generally may not disclose this specially protected information in response to a subpoena, warrant, or other legal process, unless you sign a special authorization, or a court orders the disclosure.  A general release of your 

Protected Health Information will not be sufficient for purposes of disclosing psychiatric, substance use, or HIV-related information.

1. Psychiatric information. We will not disclose records relating to a diagnosis or treatment of your mental condition between the patient and psychiatrist, or which are prepared at a mental health facility, without specific written authorization or as required or permitted by law.

2. HIV-related information. HIV-related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written authorization. As required by Connecticut law, if we make a lawful disclosure of HIV-related information, we will enclose a statement that notifies the recipient of the information that they are prohibited from further disclosing the information.

3. Substance use disorder treatment. If you are treated in a specialized substance use disorder program, information which could identify you as an alcohol or drug-dependent patient will not be disclosed without your specific authorization, except where specifically required or allowed under state or federal law.

Changes to This Notice

We reserve the right to change this Notice and make the new notice apply to Protected Health Information we already have, as well as any information we receive in the future. We will post a copy of our current notice at our office and on the Silver Hill Hospital website www.silverhillhospital.org. The notice will contain the effective date on the first page, in the top right-hand corner. 

Complaints

If you believe that your privacy rights have been violated,
you may file a complaint in writing with us to:

Health Information Management Department
Silver Hill Hospital
208 Valley Road
New Canaan, CT 06840
203.801.2348        

or with

Office for Civil Rights
Electronically through the online portal:
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf       

or in writing to

Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

Toll Free Call Center: 1-800-368-1019

TTD Number: 1-800-537-7697

Complaint forms are available at this site:
https://www.hhs.gov/ocr/complaints/index.html

You will not be penalized and we will not retaliate against you in any way for filing a complaint against Silver Hill Health or any affiliated provider of Silver Hill Health.