Effective Date: April 14, 2003
Revised: August 22, 2011
This notice describes how certain information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Nemours is required by law to:
- Make sure that certain information that identifies you is kept private,
- Give you this notice of Nemours legal duties and privacy practices with respect to certain information about you, and
- Follow the terms of the notice that are currently in effect.
Who is Nemours?
This Notice describes the privacy practices of The Nemours Foundation, a Florida Non Profit Corporation, with its principal office located at 10140 Centurion Parkway North, Jacksonville, FL 32256.
Nemours operating entities include, but are not limited to:
- Alfred I. duPont Hospital for Children in Delaware
- Nemours duPont Pediatrics (formerly Nemours Children’s Clinics) in Delaware, Pennsylvania, and New Jersey
- Nemours Cardiac Center in Delaware
- Nemours Health Center in Delaware
- Nemours Children's Hospital in Florida
- Nemours Children's Clinics in Florida
- Nemours Health and Prevention Services, Newark, Delaware
- Nemours BrightStart! Dyslexia Program
These entities, sites, and locations may share your health information with each other for treatment, payment, or health care operations as described in this Notice.
Our Pledge to You:
We understand that certain information about you and your health is personal. We are committed to protecting that information. We create a record of your care and the services you receive at Nemours. We need this information to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Nemours, whether made by Nemours’ personnel, a personal doctor, or others relating to your healthcare. Your personal doctor, if not employed by Nemours, may have different policies or notices regarding his/her use and disclosure of information created in his/her office
This notice will tell you about the ways in which Nemours may use and disclose certain information about you. This notice also describes your rights and/or your parents or guardians (personal representatives) rights, and certain obligations Nemours has regarding the use and disclosure of that information.
Who are You?
In this document, “you” refers to the patient and/or the patient’s parents or guardians.
What are your rights regarding your health information?
Access to Your Records
You have the right to inspect and/or receive a copy of your health information. In general, this includes medical and billing records, but does not include psychotherapy notes. Contact Health Information Management (HIM; located at each patient care site) to inspect or request a copy of your records. You may be charged a fee for a copy of your records.
Nemours may deny your request to view/inspect and/or provide you with a copy of your health information. If your request is denied, you may request a second review. Another licensed health care professional chosen by Nemours will review your request. Nemours will comply with the outcome of the review.
Right to Request an Amendment
You may request an amendment to your health information for as long as the information is kept by or for Nemours. Contact HIM to request an amendment.
Nemours will approve or deny your request, and notify you of our decision. If approved, Nemours will amend the information. We will also make a reasonable effort to notify people to whom the information was released. In the case of a denial, Nemours will provide the reason for the denial and instructions on how to appeal.
Right to an Accounting of Disclosures
You have the right to request a report listing people and entities with whom Nemours shared your health information. The report will not include disclosures made:
- To you,
- To third parties as authorized by you,
- For the hospital’s directory,
- To persons involved in your care or other notification purposes,
- For national security or intelligence purposes, or
- To correctional institutions or law enforcement officials.
Contact HIM to request a report. The first report you request within a 12-month period will be free. For additional reports, we may charge a fee. We will notify you of any charges involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to ask Nemours not to share your health information:
- for purposes of treatment, payment, or health care operations
- with individuals involved in your care
For example, you might request we not share information about a surgical procedure with a family member or friend.
It is often difficult for us to agree to restrictions because doing so interferes with care, but we will try to honor your request. If Nemours does agree to the restriction, we will comply with the request unless the information is needed to provide emergency treatment. Contact HIM to request a restriction.
Right to Restrict Certain Health Information
You have the right to restrict a disclosure of health care information that (1) is not otherwise prohibited by law, (2) the disclosure is to a health plan for purposes of carrying out payment or health care operations, (3) the health information pertains soley to a service or health care item for which you paid out of pocket in full, and (4) you made the request in writing prior to releasing the information. Contact HIM to exercise this right.
Right to Request Confidential Communications
You have the right to request that Nemours communicate with you about medical matters in a certain way or at a certain location. Nemours will accommodate all reasonable requests, and will not ask you the reason for the request. For example, you can ask that we only contact you at work or by mail. Contact any Nemours Manager or Nemours Privacy Officer (refer to Contact section) to make a request.
Right to be Notified in the Event of a Data Breach
Nemours will notify you if your unsecured health information is accessed, used, disclosed or acquired in a data breach. You will be sent a letter describing what happened, a description of the information that was breached, the steps you should take to protect yourself, what Nemours is doing to investigate the breach and protect you, and contact information should you have any questions.
Is Nemours always required to share your health information with you?
Not always. There are times when we may choose not to share your health information. For instance, we will not share your health information if one of our licensed health care providers:
- Feels sharing it with you could endanger you or someone else
- Determines your health information refers to another person and sharing it could harm that person
- Feels sharing your health information with your parents or legal guardian could harm you or another person
What Health Information may Nemours use and disclose without your permission?
Providers, like Nemours, are allowed to use and disclose your health information without your permission for specific purposes. Following are some of the allowed uses and disclosures.
Nemours uses and discloses your health information when planning, providing and coordinating your care. For example, uses and disclosures are made:
- To doctors, nurses, technicians, medical students, or other personnel who take care of you.
- To various departments that provide services including x-rays, prescriptions, lab tests and orthotics.
- To home health agencies, school nurses, and post discharge counselors who provide care after you leave the hospital
- Paper and Electronic disclosures of your health information are made to other providers for purposes related to treatment.
Nemours uses and discloses your health information for billing and payment processes, and to comply with insurance contracts. For example:
- Nemours gives your insurance company treatment information so they can pay us for services provided.
- Nemours also tells your insurance company about planned treatments in order to receive prior approval for the
- Paper and Electronic disclosures of your demographic information are made to other providers for purposes related
Health Care Operations
Nemours uses and discloses your health information to manage and improve care delivery and business operations. For example, we use your health information:
- to review and improve treatment methods and services, and to evaluate the performance of staff in caring for patients
- to decide what additional services should be offered and what services are not needed
- for the on-going training and education of doctors, nurses, technicians, medical and other students, and other
- in combination with information from other facilities to compare how we are doing and to see where we can make improvements in the care and services we offer
- to study health care and health care delivery after removing information that identifies individual patients
Use of Demographic Information
Nemours may also use or disclose your name, address, phone number or email address to contact you for various reasons. These may include notices about new services offered by Nemours, new locations where services are offered, the addition or departure of a provider, reminders that you have an appointment for treatment or medical care, notices about health related events, and notices about Nemours’ fund raising events.
What Health Information may Nemours use and disclose without your having an opportunity to Agree or Object?
As Required by Law
Nemours must disclose your health information when required to do so by federal, state, or local law.
Public Health Purposes
Nemours may disclose your 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 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 may be at risk for contracting or spreading a disease
Abuse or Neglect
We may disclose protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose protected health information if we believe that a patient has been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Health Oversight Activities
Nemours may disclose your 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.
To Avert a Serious Threat to Health or Safety
Nemours may use or disclose your health information when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person.
Judicial and Administrative Proceedings
If involved in a lawsuit or a dispute, Nemours may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.
Nemours may release your 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 may also release your health information to funeral directors. For example, if a patient dies of HIV, Nemours may be required to tell the funeral director.
Organ and Tissue Donation
If you are an organ donor, or on a waiting list to receive a donation/transplant, Nemours may release your 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.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, Nemours may release your health information to the correctional institution or law enforcement official. This release would be necessary 1) for the institution to provide you with health care, 2) to protect your safety or the health and safety of others, or 3) for the safety and security of the correctional institution.
Military and Veterans
If you are a member of the armed forces, Nemours may release your health information as required by military
National Security and Intelligence Activities
Nemours may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others
Nemours may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or in order to conduct special investigations.
Nemours may release your health information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons, or similar process
- To identify or locate a suspect, fugitive, material witness, or missing person
- About the victim of a crime
- About a death we believe may be the result of suspicious conduct
- About criminal conduct within a Nemours’ facility
- 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.
Nemours may disclose your health information, if you have a specific illness or condition, to a registry that maintains similar information about many patients. This information is generally used to help identify the best treatments for the illness or to keep track of how many people have the illness or condition. For example, information about patients who have cancer is provided to state registries as required by law. If Nemours wants to send information about you to registries that are not required by law or not otherwise part of “Operations” as previously described, we will ask for your authorization to disclose the information.
Nemours may use and/or disclose your health information for research purposes without your permission if an Institutional Review Board (IRB) provides a “waiver”. For example, if a Nemours researcher wants to ”look back” at patient records to find out how well a particular treatment has worked, the IRB may waive the requirement for your permission provided the study is of minimal risk, assures protection of your information, and it is not practical for the researcher to contact you for permission. Nemours may also provide information to a researcher by using a “Limited Data Set.” In this case, some, but not all, identifying information is removed from the information. The information is given to the researcher only after they agree in writing to protect it.
We may release your health information for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Nemours may disclose your health information to individuals or entities that perform health care or business related activities on our behalf. For example, private organizations that accredit (or grade) health care organizations, such as the Joint Commission on the Accreditation of Health Care Organizations, may need your health information in order to evaluate how well we do our job. Such business associates are contractually required to protect patient information the same way Nemours does.
What Health Information may Nemours use and disclose if you do not object?
Nemours may use your health information to send you educational materials related to your illness or condition, to advise you about certain treatment alternatives related to your illness or condition or to tell you about certain health-related benefits and services related to your illness or condition. For example:
- If you have diabetes, we may send you a periodic newsletter in the mail that contains information about living with diabetes.
- If you have a chronic cough, we may recommend one or more brand name cough medicines for you to purchase at a
- If you need to lose weight, we might recommend one or more commercial weight-loss programs
If you do not want to receive these materials, please contact Nemours Privacy Officer.
Nemours may use or disclose to a foundation your name, address, phone number, and dates of treatment to assist with efforts to raise money for the organization and its operations. Any fundraising effort will include an opportunity for you to tell us to remove your name from future mailings. You may also contact the Privacy Officer to be removed from fundraising efforts.
Hospital Directory (for hospital inpatients only)
Nemours may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, general condition (e.g., fair, serious, etc.), and religious affiliation. This directory information, except for religious affiliation, may also be released to people who ask for you by name. This is so your family, friends, and clergy can visit you in the hospital and generally know how you are doing. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name.
If you prefer that Nemours not release this information to friends, family, and members of the clergy, you may elect to opt out of being listed in the directory during the admitting process or at any time after being admitted. You must contact the Admitting Office to remove your information from the hospital directory.
Family Members and Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, the health information that directly relates to that person’s involvement in your health care. If due to your medical condition, you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
We may also post or display cards, letters, drawings, and photographs you give us unless you ask that we not display the item. If we do display the item, we will not disclose your name.
What about other uses of your health information?
Uses and disclosures of your health information not covered by this Notice or federal or state laws that protect your health information will be made only with your written permission as supplied with the Authorization to Use or Disclose Protected Health Information form. If you authorize Nemours to use or disclose your health information, you may revoke that permission, in writing, at any time by completing a Revocation form (available in HIM). If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. However, we will be unable to take back any disclosures we have already made based on the original authorization, and we will retain, as required, our records of the care we provided to you.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice. You may ask Nemours to give you 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. Paper copies are available at Nemours facilities.
If you have any questions about this Notice, please contact Nemours’ Privacy Officer at (904) 697-4287.
Changes to This Notice
Nemours reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for certain information we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice in all Nemours facilities, on all patient accessible websites, and copies will be available at all Nemours facilities. The effective date of the Notice will be posted in the top right-hand corner of the first page of the Notice.
If you believe your privacy rights have been violated, you may file a complaint with Nemours or with the Secretary of the Department of Health and Human Services. To file a complaint with Nemours, contact Nemours’ Privacy Officer. You will not be penalized for filing a complaint.
Nemours’ Privacy Officer
10140 Centurion Parkway North
Jacksonville, Florida 32256
(904) 697-4287 or 1-800-SOS-KIDS and ask for extension 55-4130
Health Information Management: 1-800-767-5437; then ask for HIM