Directions to Eatontown Office - Hackensack Meridian Health · Updated 6/12/2018 Hackensack...

Updated 6/12/2018

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC www.meridianpediatricsurgery.com

Directions to Eatontown Office

Route 18 (North or South) Take to exit 13B-Route 36 East

Travel 1 mile to 3rd

light and make right onto Route 35 S

Travel almost 1 mile to 2nd

traffic light and make a right on Industrial Way West

Turn into 1st driveway on right (Meridian Center 2/4/6)

Make 2

nd right

Our building at 4 Industrial Way West is directly in front of you.

Make left and park on the side of building in one of our convenient parking spots.

Access through glass front doors past bench.

Garden State Parkway Coming from the South Take GSP Exit 105

Follow signs for Route 36 East

Take Route 36 East 1.5 and make right at 3rd

light-Route 35 South

Follow directions from above

Garden State Parkway Coming from the North Take GSP Exit 105

Take route 36 East 1.5 and make right at 3rd

light-Route 35 South

Follow directions from above

***FYI, we are on the opposite side of Industrial Way from Homewood Suites by Hilton***

Victoriya Staab, M.D.

Christine M. Williams, PA-C

4 Industrial Way West, Suite 100,Eatontown,NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

http://www.meridianpediatricsurgery.com/

Updated 6/12/2018

Hackensack Meridian Pediatric Surgical Associates, PC (As a safeguard for your privacy, DO NOT e-mail these forms back to us. However, you may fax

them back to us to our secure fax #732-935-0757, if this is convenient for you.)

The following is the “patient information” forms that we require. Please fill out these

forms in their entirety and bring them with you for your appointment along with your

insurance card(s) and parent/guardian must have a photo ID. If you are not the

biological parent, please bring proof of legal guardianship. We cannot treat your child

without it. If your child is 18 years of age or older, please make sure they also bring

their ID.

Please fill in both “legal” parents information on the attached forms.

Without it, we cannot release any health information to them.

Please be aware, we also need a script from your child’s pediatrician requesting the

consultation with our doctor(s). It must state the reason for the consultation. If your

insurance company mandates the use of a referral form, that form will be sufficient.

Due to the nature of the specialty as pediatric surgeon, we may experience the need to

insert emergency appointments during our regularly-scheduled appointment times. We

do not anticipate a long wait, but in order for the doctor to give each patient the time

and attention required, you might experience a longer wait time. We do our best to

avoid this from occurring and would greatly appreciate your patience and understanding

if this should occur. Our goal is to have your child seen within 1 hour of their

scheduled appointment time, but usually it is much sooner.

We strive to provide the

“Best Health Care Experience”.

Please let us know how we are doing.

After your visit with our doctor, you may receive a survey through

your email. If there is no response is received, or you do not have an

email, you may get an automated call. Please take the time to

complete the survey for us.

Thank you. --The Staff at Hackensack Meridian Pediatric Surgical Associates, PC

Updated 6/12/2018

PEDIATRIC PATIENT REGISTRATION- PERSONAL INFORMATION

Patient’s Name:

1. _____________________________________________ DOB ___________________Sex: Male Female (Circle One)

2. _____________________________________________ DOB ___________________Sex: Male Female (Circle One)

*What is the reason for today’s visit? ______________________________________________________________________

*Name of Pediatrician: _________________________________Town: _______________________ Tel#________________

Did they refer you to us? _____________________ If not, who did? ____________________________________________

Language spoken at home: ___________________ Pharmacy name & phone: _____________________________________

Race: American Indian/Alaska Native Asian Black/African American

Native Hawaiian /Other Pacific Islander White Choose not to answer

Ethnicity: Hispanic/Latino Not Hispanic/Latino Choose not to answer

Parent/Guardian: _____________________________DOB: ___________Relationship to patient(s): ___________________

Home Address: (Street) _____________________________________ (City/State) _______________________ (Zip) ________

Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home

Preferred Method of Contact (please circle): Phone US mail Email via secure portal

Email Address: _____________________________________ Employer: __________________________________________

Parent/Guardian: ___________________________DOB: ___________Relationship to patient(s): _____________________

Home Address: (Street) ______________________________________ (City/State) ______________________ (Zip) ________

Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home

Email Address: _____________________________________ Employer: __________________________________________

Emergency Contact: ____________________________Phone:_____________________Relationship:____________________

INSURANCE INFORMATION

Primary Insurance Co. Information: (name, address and phone # of person responsible for payment)

Insurance Company Name: _____________________________________________Phone: ___________________________

Policy/ID Number: ____________________________Group #: __________________ Effective Date: __________________

Subscriber’s Name: _____________________________________ Relationship to Patient____________________________

Subscriber’s DOB: _______________

Ins. Address: __________________________________________________________________________________________

Secondary Insurance Co. Information: (name, address and phone # of person responsible for payment)

Insurance Company Name: ______________________________________________ Phone: ___________________________

Policy/ID Number: _____________________________ Group #: ________________ Effective Date: ____________________

Subscriber’s Name: _______________________________________ Relationship to Patient____________________________

Subscriber’s DOB: ____________________

Ins. Address: ___________________________________________________________________________________________

Signature: _______________________________________________________________ Date: ______________________

Hackensack Meridian Pediatric Surgical Associates

Updated 6/12/2018

BARRIER TO CARE:

State of New Jersey mandates that every physician documents any barrier to care including cultural

and linguistic needs in the medical record. Factors affecting care are visual or auditory factors

which may impede your ability to comprehend medical discussion and language, cultural and/or

religious customs, which may impact the provider’s ability to provide medical care. Addressing

these needs will improve patient satisfaction and also decrease health care disparities.

Do you have any Impairment – (i.e. Visual, hearing, speech, learning, physical and language/cultural

barrier) _______________________________________________________________________

What language do you speak, read or write? __________________________________________

Do you have any religious or culture customs that the doctor should know about?

Yes No ____________________________________________________

Patient’s Name: _____________________________________ DOB: __________________

Legal Guardian’s Signature: __________________________________________________

Relationship________________________________________________________________

Date: ______________________________________________________________________

*****Laboratory and Radiology Services*****

We have our testing done at Jersey Shore University Medical Center, as we can obtain your

child’s results faster and our doctor has constant communication with the radiologists.

However, if your insurance requires you to use a specific facility please let us know.

Which laboratory facility do you use? LabCorp Quest Other: _____________________

Which facility do you use for imaging studies? _______________________________________

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC


Christine M. Williams, PA- C

4 Industrial Way West Suite 100, Eatontown, NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

www.meridianpediatricsurgery.com

Updated 6/12/2018

PERMISSION TO RECEIVE PRERECORDED MESSAGES AND/OR TEXT MESSAGES

As a service to our patients, we provide courtesy appointment reminder calls and when we can text messages. We also

may place other important calls and send text messages using a prerecorded or automated message. In order to authorize

receiving the calls and messages, please fill out the information below and provide the phone number where you wish to

receive these messages.

Important note: By providing your cell phone number below, you consent to receiving appointment reminder calls,

important calls and/or text messages on your cell phone. If you would like us to utilize a different number—please provide

that number below instead of your cell phone number.

This authorization permits us to leave messages, call or text you on the phone number that you provide below. If you

provide your cell phone number, you will receive automated or prerecorded messages on your cell phone. We are required

by law to advise you of this.

You do not need to sign this authorization; however, - if you do not sign this authorization, we will not be able to provide

you with courtesy reminder calls, text messages or other important calls.

Patient Name __________________________________ Patient date of birth: ______________

Legal Guardian if a minor: __________________________________Relationship: ______________

Signature of Parent or Legal Guardian _______________________________ (if patient is a minor)

Phone number authorized by Patient to receive calls and message as set forth above:

Cell Phone Number: __________________________

Telephone Number: __________________________

Date_____________________





Phone: 732-935-0407 Fax: 732-935-0757


Updated 6/12/2018

Patient’s Name: ___________________________________ Date of Birth: ____________

Payment Policy

We are committed to providing you with quality and affordable health care. Some of our patients

have questions regarding patient and insurance responsibility for services rendered, so we’ve

developed this payment policy. Please read it, ask us any questions you may have, and sign in the

space provided. A copy will be provided to you upon request.

1. Insurance. If you are not insured by a plan we do business with, payment in full is expected at

each visit or with-in 14 days of the billing statement. If you are insured by a plan we do business

with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we

can verify your coverage or with-in 14 days of the billing statement. Knowing your insurance

benefits is your responsibility. Please contact your insurance company with any questions you may

have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of

service. This arrangement is part of your contract with your insurance company. Failure on our part

to collect co-payments and deductibles from patients can be considered fraud. Please help us in

upholding the law by paying your co-payment at each visit.

3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive

may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You

must pay for these services at time of service or with-in 14 days of billing statement.

4. Proof of insurance. All patients must complete our patient information form before seeing the

doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of

insurance. If you fail to provide us with the correct insurance information in a timely manner, you

may be responsible for the balance of a claim.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to

help get your claims paid. Your insurance company may need you to supply certain information

directly. It is your responsibility to comply with their request. Please be aware that the balance of

your claim is your responsibility whether or not your insurance company pays your claim. Your

insurance benefit is a contract between you and your insurance company; we are not party to that

contract.

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can

make the appropriate changes to help you receive your maximum benefits. If your insurance

company does not pay your claim in 60 days, the balance will automatically be billed to you.

Initial ______________





Phone: 732-935-0407 Fax: 732-935-0757


Updated 6/12/2018

7. Nonpayment. Partial payments will not be accepted unless otherwise negotiated. Please be aware

that if a balance remains unpaid, we may refer your account to a collection agency authorized to credit

report all outstanding debts to the four major National Credit Agencies, litigate in a court of law (other

legal fees my apply) and charge a service fee of 30% of the outstanding balance in the event that we

incur additional pre-collection and collection fees to reach a final resolution of any outstanding

balance for which you owe the practice.

8. Additional Cost of Collection Services. Invoices shall be deemed to be accepted by you unless Meridian Pediatric Surgical Associates, PC is notified in writing within 14 days of the invoice being issued that you dispute the amount of the invoice. In the event of non-payment, Hackensack Meridian Pediatric Surgical Associates, PC may in addition to the invoice amount charge:

(i.) Interest on any outstanding amounts from the due date calculated at the statutory penalty rate of 16%. (ii) Legal and debt collection fees incurred by Hackensack Meridian Pediatric Surgical Associates, PC in relation to recovery of outstanding amounts.

Where any part of your medical account with Hackensack Meridian Pediatric Surgical Associates, PC has fallen into arrears then the totality of that account whether or not in arrears shall become immediately due and payable.

9. Missed appointments. Our policy is to charge $30 for missed appointments not cancelled within

24 business hours. These charges will be your responsibility and billed directly to you. Please help us

to serve you better by keeping your regularly scheduled appointment or call 24 hours prior to cancel

your scheduled appointment.

Our practice is committed to providing the best treatment to our patients.

Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy.

Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

_____________________________________________ ______________________

Signature of patient or responsible party Date

Patient’s Name: _______________________________________ Date of Birth: _____________

Updated 6/12/2018

CONSENT FOR TREATMENT:

I acknowledge that I have elected on my own behalf or on behalf of my dependent to receive

medical services that may or may not be covered by my health plan or any number of reasons.

I understand and acknowledge that I am financially responsible for, and therefore shall pay for, all

services rendered to me or my dependent that are not paid or contractually adjusted by my insurance,

in whole or in part, by my health plan for any reason whatsoever.

RELEASE OF INFORMATION:

I authorize the release of all information necessary to process my insurance claims and pertinent to

my medical care. This release will remain in effect until revoked by me in writing. A photocopy of

this release is to be considered as valid as the original.

ASSIGNMENT OF BENEFITS:

I assign all medical and/or surgical benefits including major medical benefits to which I am entitled,

including Medicare, BCBS, HMO plans, and commercial insurance to (insert practice name) This

assignment will remain in effect until revoked by me in writing. I hereby authorize the above to

release information to secure payment on my behalf.

I understand that I am financially responsible for all charges. I have read this information and

understand it.

Patient Name: _______________________________ DOB: _________________________

Signature of Parent or Guardian: _______________________________________________

(If patient is a minor.)

Signature: ___________________________________________________________________

Date: ___________________________________





Phone: 732-935-0407 Fax: 732-935-0757


Updated 6/12/2018

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES

Patient Name: ____________________________________ Date of Birth: __________ Age: ___________ Sex: Male Female

Weight at birth? _________ Hospital: __________Country? ________ Full term? Yes / No born @______gestation Vaginal/ C-Section

Is child a multiple? Yes No , If Yes, (twin) (triplet) (quadruplet) Birth Order: ___ Conceived by In-Vitro Fertilization? Yes No

Apnea Monitor: Currently being used or was it used? If yes, When? ___________ When was it stopped? ________________

Male Patient: Circumcised: Y N - If yes, Date: _____________________ Hospital: ________________________________

Female patient: Menstruating: Y N Onset _________________________ Last ______________________________________

Current Medications: (Including Vitamins, Over the Counter, Herbs etc.)

Medication Condition Being Treated

Does your child have any ALLERGIES: Please Answer Each Question (Circle Answer)

Type of Allergy: (Circle Answer) Reaction Type

Shellfish Yes No

Latex Yes No

Anesthesia Yes No

Surgical Adhesive Yes No

Environmental Yes No

Any Allergy to Medications Yes No

*** If so please list:

Other Allergies (please list):

Has ANY biological family member had a

problem with anesthesia?

Yes-Relationship __________________________________

No

Does your child have any IMPORTANT MEDICAL CONDITIONS: Please Answer Each Question

(Circle Answer)

Does your child have or had: If yes, list type of condition Name of treating physician

Any blood conditions Yes No

Asthma Yes No Last episode:

Heart Problems/Murmur Yes No

Diabetes Yes No Insulin Dependent? Yes No

Neurological Yes No

Has your child had any OPERATIONS/ HOSPITALIZATIONS? (Including Overnight Observations) Procedure / Reason for Hospitalizations Date Hospital/ Doctor

_______________________________ _________________ ________________ SIGNATURE DATE TIME

__________________ __________ Signature Review Date

______________________________ ______________

Signature Review Date For updating use only

Patient Name: ____________________________________________ Date of Birth: _____________________________

*Patient Review of Systems* Please check the box to the right of the condition if your child presently has or has been previously diagnosed with any of the

following. If condition is resolved, please put an “R” in the box. Constitutional:

Fatigue Night Sweats Weight Loss

Failure to Thrive Other _____________________________ Integumentary/Skin:

Rash Lesion Abscess

Eczema MRSA Other ____________

Neurological:

Cerebral Palsy ADD ADHD

Convulsions Epilepsy Asperger’s Syndrome

Seizures Fainting Spells Autism

Paralysis Stroke Dizziness

VP Shunt Headaches Other____________

Respiratory:

Chronic Cough Lung Disease Empyema

Pneumonia Tuberculosis Tracheostomy

RSV Asthma (please also list on other side)

Pulmonary Embolism Bronchopulmonary Dysplasia

TE Fistula Other _____________________________

Cardiac:

Murmur Enlarged Heart Rheumatic Fever

Irregular Heart Beat Congenital Heart Disease

Mitral Valve Prolapse Other____________________________

Intestinal & GU:

Colitis/IBS Constipation Necrotizing Entercolitis

Gallstones Kidney Stone Kidney Infection

Bed Wetting Ulcer GE Reflux Disease

Gallbladder Disease Diarrhea Imperforate Anus

Difficulty Swallowing Ovarian Cysts Frequent Urination

Vomiting/Nausea Hydronephrosis Biliary Dyskinesia

Retractile Testes Crohn’s Disease Undescended Teste

Breast Mass/cyst Other_____________________________

Hematology & Lymphatic:

Hepatitis Bruising Lyme disease

Nosebleeds Anemia Sickle Cell

Circulatory Disease Epstein-Barr Blood Clotting Disease

Mononucleosis Other_____________________________

Oncology:

Cancer Leukemia Radiation Therapy

Wilms’ Tumor Chemotherapy Other ____________

Allergy & Immune:

Seasonal Allergies Mitochondrial Deficiency

HIV/AIDS Other______________________________

Genetics:

Down syndrome Cystic Fibrosis Marfan’s syndrome

Other: __________________________________________________

Endocrine:

Diabetes Hyper or Hypo Thyroidism

Growth Deficiency Other _____________________________

Psychological:

Depression Bipolar Schizophrenia

Anxiety OCD Other_____________

*SOCIAL HISTORY*

Number of siblings? _____________________

Is your child in daycare? Yes No

Does your child attend school? Yes, Grade ____ No

Is your child home schooled? Yes No

Is your child in college? Yes No

Who is the child’s legal guardian? _______________________

With whom does the child reside? _________________________

Who is the primary caregiver for your child, and what is the

relationship to the child? ________________________________

Please list any sports or extra-curricular activities your child

participates in. If none, please check

____________________________________________________

____________________________________________________

*BIOLOGICAL FAMILY HISTORY* If any biological family members have any medical conditions,

please indicate what conditions.

Adopted? Yes No (please circle) Country____________

If adopted, please complete below.

Were you informed of any pertinent family history? Yes No

Would you rather we not disclose in front of child? Yes No

(Check box if deceased & provide condition)

Mother____________________________________________

Father____________________________________________

Siblings___________________________________________

Maternal Grandmother________________________________

Maternal Grandfather_________________________________

Paternal Grandmother________________________________

Paternal Grandfather_________________________________

Other_____________________________________________

Do you have pets at home or does your child come in contact with

pets on a consistent basis? Yes No (If so, list type)

__________________________________________________________

If there is any other information that you would like us to know

about your child? Please inform us in the space below.

___________________________________________________________

____________________________________________

______________________________ ______________

Signature Review Date

______________________________ ______________

Signature Review Date For updating use only

SIGNATURE DATE TIME

For Internal Use Only: Scan document into HIPPA form folder in CB Revised 5/14

Acknowledgment of Receipt of Notice and Approval of Privacy Practices

Patient Name: ________________________________ Patient’s Date of Birth: _______________________

I, ______________________________________________, hereby acknowledge that I have

received the corresponding HIPAA Notice of Privacy Practices. I also further acknowledge and

approve the uses and disclosures of my PHI as described in the HIPAA Notice of Privacy Practices.

Date: ______________________.20______ ____________________________________

Signature of Patient or Representative

Patient Contact Authorization

I, ______________________________________________, (patient or legal representative name)

authorize and give permission to Meridian Pediatric Surgical Associates, or any practice staff

members, to leave messages regarding ___________________________ (fill in patient’s name)

medical information on the following telephone(s):

Home: ( ) ____________-_______________

Cell: ( ) ____________-_______________

I authorize and give permission to Meridian Pediatric Surgical Associates, or any practice staff members,

to speak with the following people regarding ______________________________ (fill in patient’s name)

medical status and/or treatment

Name: ______________________________________ Relationship: _______________________



Patient Signature: _______________________________ Date: ___________________________





Phone: 732-935-0407 Fax: 732-935-0757


This Joint Notice of Privacy Practices (“Notice”) explains how Hackensack Meridian Health (collectively “HMH”) uses information about you and when HMH can share

that information with others. It also informs you about your rights as a valued customer.

This Notice is being provided to you on behalf of HMH, which includes our hospitals (see below listing), Meridian Home Care Services, Inc., Meridian Nursing and

Rehabilitation, Inc., and the independent members and independent health professional affiliates of the medical staffs of HMH (collectively with “HMH” referred to

herein as “us”, “we” or “our”) with respect to services provided by HMH. Please note that the independent members and independent health professional affiliates of the

medical staffs are neither employees nor agents of HMH, but are joined under this Notice for the convenience of explaining to you your rights relating to the privacy of

your protected health information (“PHI”).

HMH respects the privacy and confidentiality of your PHI. The federal law, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), sets rules about

who can look at and receive your health information. This law, and applicable state law, gives you rights over your health information, including the right to get a copy of

your health information, make sure it is correct, and know who has seen it.

Please review this Notice carefully.

ORGANIZED HEALTH CARE ARRANGEMENT (“OHCA”)

An Organized Health Care Arrangement (“OHCA”) is an arrangement or relationship that

allows two or more HIPAA covered entities to use and disclose PHI. A HIPAA covered entity

is any organization or corporation that directly handles PHI or Personal Health Records (PHR).

The most common examples of covered entities include hospitals, doctors’ offices and health

insurance providers. The entities participating in the HMH OHCA are covered entities under

HIPAA and will share PHI with each other, as necessary to carry out treatment, payment or

health care operations relating to the OHCA. The entities participating in the HMH OHCA agree to abide by the terms of this Notice with

respect to PHI created or received by the entity as part of its participation in the OHCA. The

entities, which comprise the HMH OCHA, are in numerous locations throughout the greater

New Jersey area. This Notice applies to all of these sites. For a complete list of locations,

please refer to last page of this Notice.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION Each time you visit or interact with a hospital, physician, or other health care provider, a record

of your visit is made. Typically, this record contains your symptoms, examination and test

results, diagnoses, treatment, and a plan for future care or treatment. This information, often

referred to as your health or medical record, serves as a:

Basis for planning your care and treatment

Means of communication among the many health professionals who contribute to your care

Legal document describing the care you received

Means by which you or a third-party payer can verify that services billed were actually provided

A tool in educating health professionals

A source of data for medical research

A source of information for public health officials charged with improving the health of the nation

A source of data for facility planning and marketing

A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy

Better understand who, what, when, where, and why others may access your

health information

Make more informed decisions when authorizing disclosure to others

YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of the health care practitioner or facility

that compiled it, the information belongs to you. You have the right to:

Request a restriction on certain uses and disclosures of your information, however, HMH is not required to agree to such a request if the facts do not warrant it.

Obtain a paper copy of the Notice of Privacy Practices upon request

Inspect and obtain a paper or electronic copy of your health record usually within

30 days of your request. We may charge a reasonable, cost-based fee.

Request an amendment (correction) to your health record if you believe

information is incorrect or incomplete

Obtain a list (an accounting of disclosures) of the times we have shared your health information for six years prior to the date you asked, who we shared it with,

and why. Exceptions: treatment, payment and health care operations.

Request communications of your health information by alternative means or at

alternative locations. For example, you may request that we send correspondence to a post office box rather than your home address.

Revoke your authorization to use or disclose health information except to the extent that action

has already been taken. If you pay for a service out-of-pocket in full, you can request that

information not be shared for the purpose of payment or our operations with your health

insurer.

You will be asked to sign an acknowledgment that you have received this Notice. We are

required by law to make a good faith effort to provide you with the Notice and to obtain

your acknowledgment. Your refusal to accept the Notice or to sign the acknowledgment will in no way affect your care or treatment in our facility.

HACKENSACK MERIDIAN HEALTH’S RESPONSIBILITIES

Maintain the privacy and security of your health information

Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you

Abide by the terms of this Notice

Notify you if we are unable to agree to a requested restriction

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location

Notify you if a breach occurs that may have compromised the privacy or security of your information

We reserve the right to change our practices and to make the new provisions effective for

all PHI we maintain. Should our information practices change, revisions will be available

at www.HackensackMeridianHealth.orq and you may request a revised copy from the

Office of Privacy, the Office of Patient Experience or any patient registration areas. The

HMH Chief Compliance Officer is responsible for maintaining the Notice of Privacy

Practices and for archiving previous versions of the Notice.

We will not use or disclose your health information without your authorization, except as described in this Notice and for treatment, payment, or health care operations.

Note: HIV-related information, genetic information, alcohol and/or substance abuse

records, mental health records or other specially protected health information may have

additional confidentiality protections under applicable State and Federal law. We will

obtain your specific authorization before using or disclosing these types of information

where we are required to do so by such applicable State and Federal laws. However, we

may be permitted to use and disclose such information to our physicians to provide you with treatment.

EXAMPLES OF PERMITTED DISCLOSURES OF PROTECTED HEALTH

INFORMATION FOR TREATMENT, PAYMENT & HEALTH CARE

OPERATIONS

We will use your health care information for Treatment.

For example: Information obtained by a nurse, physician, or other member of your health

care team will be recorded in your record and used to determine the course of treatment. Members of your health care team will record the actions they took, their observations, and

their assessments. In that way, your health care team will know how you are responding to

treatment. We will also provide your physician or a subsequent health care provider with

copies of various reports that should assist him or her in treating you once you are

discharged from this facility.

We will use your health care information for Payment.

For example: A bill will be sent to you and/or a third-party payer (insurance company).

The information on the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may provide copies of the applicable

portions of your medical record to your insurance company in order to validate your claim.

We will use your health care information for regular Health Care Operations.

For example: We may use and disclose PHI for activities that HMH engages in to operate

its business, such as quality assurance, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits,

business planning, development and the management of health outcomes, including the

identification of opportunities to improve the health of individuals or groups of individuals.

In addition, we may remove information that identifies you from your patient information

so that others can use the de-identified information to study health care and health care

delivery and implement quality improvement initiatives without learning who you are.

OTHER USES & DISCLOSURES OF PROTECTED HEALTH INFORMATION

HEALTH INFORMATION EXCHANGE HMH, along with other health care providers in New Jersey participate in Jersey Health

Connect, a health information exchange (“HIE”) which allows patient information to be shared electronically through a secured network that is accessible to the providers treating you. We

may disclose your PHI to the HIE unless you opt out of participating. To opt out, please contact

Jersey Health Connect at (855) 624-6542.

PERSONAL HEALTH RECORD

A personal health record (PHR) is an electronic application used by patients to maintain and

manage their health information in a private, secure, and confidential environment. PHRs:

Are managed by patients

Can include information from a variety of sources, including health care providers and patients themselves

Can help patients securely and confidentially store and monitor health information, such as diet plans or data from home monitoring systems, as well as patient contact

information, diagnosis lists, medication lists, allergy lists, immunization histories, and

much more

Are separate from, and do not replace, the legal record of any health care provider

Are distinct from portals that simply allow patients to view provider information or

communicate with providers

Note: In addition to the HIE, HMH uses MyChart which allows you to exchange secure

electronic messages with your physician or allows you to request medical appointments. Kindly

check with your HMH provider to see which PHR applies to you.

BUSINESS ASSOCIATES We may disclose your health information to contractors, agents and other associates who need

this information to assist us in carrying our business operations. Our contracts with them

require that they protect the privacy of your health information in the same manner as we do.

FACILITY DIRECTORY Unless you notify us that you object, HMH will release your name and location to the general

visiting public while you are a patient in a HMH facility. In addition, your religious affiliation

will be made available to the visiting clergy.

NOTIFICATION We may use or disclose information about your location and general condition to notify or

assist in notifying a family member, personal representative, or another person responsible for your care.

COMMUNICATION WITH FAMILY As long as you do not object, your health care provider is permitted to share or discuss your

health information with your family, friends, or others to the extent that they are involved in

your care or payment for your care. Your provider may ask your permission or may use his or

her professional judgment to determine the extent of that involvement. In all cases, your health

care provider may discuss only the information that the person involved needs to know about your care or payment for your care.

RESEARCH We may disclose information to researchers when their research has been approved by HMH.

INSTITUTIONAL REVIEW BOARD (“IRB”) The IRB reviews the research proposals and establishes protocols to ensure the privacy of your

health information.

FUNERAL DIRECTORS OR CORONERS We may disclose health information to funeral directors or coroners consistent with applicable

law to carry out their duties.

ORGAN AND TISSUE DONATION If you are an organ donor, we may release PHI 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.

TELEPHONE CONTACT/APPOINTMENT REMINDERS We may contact you to provide appointment reminders or information about treatment

alternatives or other health-related benefits and services that may be of interest to you. We may

call you after you have been a patient to ask about your clinical condition or to assess the

quality of care that you received.

FUNDRAISING The Hospitals of HMH affiliated Foundations may contact you as part of a fundraising effort.

The information used for this purpose will not disclose any health condition, but may include

your name, address, phone number, email address, etc. When contacted, you may ask that we

stop any future fundraising requests if you so desire.

IMAGES

The hospitals of HMH may record digital or film images of you, in whole or in part, for

identification, diagnosis or treatment purposes and for internal purposes such as performance improvement or education. Such images may be used for documenting or planning care,

teaching, or research. The medical center will obtain your authorization for any other use your

identifiable image that is unrelated to treatment, payment or heath care operations.

FOOD AND DRUG ADMINISTRATION (“FDA”)

We may disclose to the FDA health information relative to adverse events with respect to

food, supplements, product and product defects, or post marketing surveillance information

to enable product recalls, repairs, or replacement.

WORKERS COMPENSATION

We may disclose health information to the extent authorized and to the extent necessary to

comply with laws relating to worker’s compensation or other similar programs established by law.

OCCUPATIONAL HEALTH

We may disclose your PHI to your employer in accordance with applicable law, if we are

retained to conduct an evaluation relating to medical surveillance of your workplace or to

evaluate whether you have a work-related illness or injury. You will be notified of these

disclosures by your employer or HMH as required by applicable law.

PUBLIC HEALTH & SAFETY

As required by law, we may disclose your health information to public health or legal

authorities charged with preventing or controlling disease, injury, or disability.

CORRECTIONAL INSTITUTION

If you are an inmate of a correctional institution or under the custody of a law enforcement

official, we may release PHI about you 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 health and safety or the health and safety of others; or (3) for the

safety and security of the correctional institution.

LAW ENFORCEMENT

We may release PHI 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 under certain limited circumstances;

About a death we believe may be the result of criminal conduct;

About criminal conduct on our premises; and

To report a crime, the location of the crime or the victims, or the identity,

description or location of the person who committed the crime.

Federal law makes provision for your PHI to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business

associate believes in good faith that we have engaged in unlawful conduct or have

otherwise violated professional or clinical standards and are potentially endangering one or

more patients, workers or the public

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you believe that your privacy rights have been violated, you should immediately contact

the Office of Patient Experience with the entity from which you received services or the

HMH Privacy Office. You may also file a complaint with the Secretary of Health and Human Services at (877) 696-6775 or by visiting

www.hhs.gov/ocr/privacy/hipaa/complaints/. There will be no retaliation for filing a

complaint.

HACKENSACK MERIDIAN HEALTH HOSPITALS

• HackensackUMC

• Jersey Shore University Medical Center

• Joseph M. Sanzari Children’s Hospital

• K. Hovnanian Children’s Hospital

• Ocean Medical Center

• Riverview Medical Center

• HackensackUMC Mountainside

• HackensackUMC Palisades

• Raritan Bay Medical Center in Perth Amboy

• Southern Ocean Medical Center

• Bayshore Community Hospital

• Raritan Bay Medical Center in Old Bridge

• HackensackUMC at Pascack Valley

Effective July 1, 2016

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