HIPPA Privacy Rule Notice
Gastrointestinal Group of North Jersey, P.A.
1777 Hamburg Turnpike - Suite 101
Wayne, NJ 07470
Notice of Privacy Practices: This notice describes how medical information about you may be used and disclosed by our practice
and how you can get access to this information. Please review it carefully. If you have questions about this Notice you may contact
our Privacy Officer, Maureen Petrillo, at 973-839-6400.
A federal regulation, known as the "HIPPA Privacy Rule," requires that we provide detailed notice in writing of our privacy
practices. The HIPPA Privacy Rule requires us to address many specific things in this Notice.
OUR COMMITMENT TO PROTECTING HEALTH INFORMATION ABOUT YOU
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment,
payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights
to access and control your protected health information. "Protected health information" is information about you, including
demographic information, that may identify you and that relates to your past, present or future physical or mental health or
condition and related health care services. We are required by law to:
> Maintain the privacy of protected health information about you;
> Give you this Notice of our legal duties and privacy practices with respect to protected health information, upon your request;
> Comply with the terms of our Notice of Privacy Practices currently in effect.
We reserve the right to make changes to this Notice and to make such changes effective for all protected health information we
may already have about you. If and when this Notice is changed, we will post a copy in our office in a prominent location and on
our website (www.gastrogroup.com). We will also provide you with a copy of the revised Notice upon your request made to our
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Uses and Disclosures of Protected Health Information Based upon Your Written Consent: You will be asked by our staff to sign
a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and
health care operations by signing the consent form, your physician will use or disclose your protected health information as
described in this Section 1. Your protected health information may be used and disclosed by your physician, our office staff and
others outside of our office that are involved in your care and treatment for the purpose of providing health care services to
you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation
of the physician's practice. Following are examples of the types of uses and disclosures of your protected health care information
that the physician's office is permitted to make once you have signed our consent form. These examples are not meant to be ex-
haustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and
any related services. This includes the coordination or management of your health care with a third party that has already ob-
tained your permission to have access to your protected health information. For example, we would disclose your protected health
information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information
to other physicians who may be treating you when we have the necessary permission from you to disclose your protected health
information. For example, your protected health information may be provided to a physician to whom you have been referred to
ensure that the physician has the necessary information to disclose or treat you. In addition, we may disclose your protected
health information from time-to-time to another physician or health care provider who, at the request of your physician, becomes
involved in your care by providing assistance with your health care diagnosis or treatment to your physician. (For example, we
may use and disclose protected health information when you need a prescription, lab work, x-ray, anesthesia or other health
care services. We may also disclose any allergic reactions you may have to medications. We may send a report about your care
from us to a physician that we refer you to so that the other physician may treat you.)
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services (billing,
claims management, and collection activities). This may include certain activities that your health insurance plan may undertake
before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility
or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review
activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose,as needed, your protected health information in order to support the business
activities of the Gastrointestinal Group of North Jersey, P.A. These activities include, but are not limited to, quality assessment
activities (activities assisting us in deciding how we can improve the medical treatment we provide), employee review activities (re-
viewing and evaluating the skills, qualifications, and performance of health are providers taking care of you and our other patients),
licensing (licensing of health care providers or staff in a particular field or specialty), marketing activities (identifying groups of
people with similar health problems to give them information , for instance, about treatment alternatives, and educational classes to
help manage and coordinate care for them), and conducting or arranging for other business activities. (Examples of protected health
information disclosures include billing personnel, certifying a nurse as having expertise in a specific field of nursing, assisting
our accountants, lawyers and others who assist us in complying with the law and managing our business and for making plans for
our practice's future operations.) We may use a sign-in sheet at the registration desk where you will be asked to sign your name
and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use
or disclose your protected health information, as necessary, to contact you to remind you or your appointment. We may use or
disclose your protected health information (your name and address) in communicating your need for follow up care or to provide
you with information about treatment alternatives or other health related benefits and services that may be of interest to you.
We may also disclose your protected health information for the health care operations of an "organized health care arrangement"
in which we participate, such as: the joint care provided by a hospital and the doctors who see patients at the hospital. You may
contact our Privacy Official to request that any of these not be sent to you or ask that they be sent to another address.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of
your protected health information will be made only with your written authorization, unless otherwise permitted or required by law
as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the Gastro-
intestinal Group of North Jersey, P.A. has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity
to Object: We may use and disclose your protected health information in the following instances. You have the oppor-
tunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or
able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional
judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is
relevant to your health care will be disclosed.
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, your protected health information that directly relates to that person's involvement
in your health care. If you are unable to agree or object to such a disclosure, we 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 protected 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. (Example: If you are brought to the office and are unable to communicate
normally with your physician for some reason, we may find it in your best interest to give your prescription and other medical
supplies to the person or relative who brought you in for treatment. We may also use professional judgment and our experience
with common practice to make reasonable decisions about your best interests in allowing a person to act on your behalf to pick
up filled prescriptions, medical supplies, x-rays, or other things that contain protected health information about you.)
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this
happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.
If your physician or another physician in the Gastrointestinal Group of North Jersey, P.A. is required by law to treat you
and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or dis-
close your protected health information to treat you.
Communication Barriers: We may use and disclose your protected health information if your physician or another physician
in the Gastrointestinal Group of North Jersey, P.A. attempts to obtain consent from you but is unable to do so due to substantial
communication barriers and the physician determines, using professional judgment, that you intend to consent to use or dis-
closure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity
to Object: We may use or disclose your protected health information in the following situations without your consent or
authorization. These situations include:
Required By Law: We may use of disclose your protected health information to the extent that the use
or disclosure is required by law. The use or disclosure will be made in compliance with the law and
will be limited to the relevant requirements of the law. You will be notified, as required by law, of any
such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and pur-
poses to a public health authority that is permitted by law to collect or receive information. The disclosure
will be made for the purpose of controlling disease, injury or disability. We may also disclose your pro-
tected health information, if directed by the public health authority, to a foreign government agency that
is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a
person who may have been exposed to a communicable disease or may otherwise be at risk of contracting
or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities
authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this infor-
mation include government agencies that oversee the health care system, government benefit programs,
other government regulatory programs and civil rights laws.
Abuse or Neglect, or Domestic Violence: We may disclose your 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 your protected health information if we believe that you have been a victim of abuse, neglect
or domestic violence to the government entity or agency authorized to receive such information. In this
case, the disclosure will be made consistent with the requirement of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company
required by the Food and Drug Administration to report adverse events, product defects or problems, bio-
logic product deviations, track products; to enable product recalls; to make repairs or replacements, or
to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or administrative tribunal (to the extent
such is expressly authorized), in certain conditions in response to a subpoena, discovery request or
other lawful process.
Law Enforcement: We may disclose protected health information, so long as applicable legal require-
ments are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes
and otherwise required by law, (2) limited information requests for identification and location purposes,
(3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct,
(5) in the event that a crime occurs on the premises of the Gastrointestinal Group of North Jersey, P.A.,
and (6) medical emergency (not on the Gastrointestinal Group of North Jersey, P.A.'s premises) and it is
likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a
coroner or medical examiner for identification purposes, determining cause of death or for the coroner or
medical examiner to perform other duties authorized by law. We may also disclose protected health infor-
mation to a funeral director, as authorized by law, in order to permit the funeral director to carry out
their duties. We may disclose such information in reasonable anticipation of death. Protected health
information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research has
been approved by an institutional review board that has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected
health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious
imminent threat to the health or safety of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose
protected health information of individuals who are Armed Forces personnel (1) for activities deemed neces-
sary by appropriate military command authorities; (2) for the purpose of determination by the Department
of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a
member of that foreign military services. We may also disclose your protected health information to auth-
orized federal officials for conducting national security and intelligence activities, including for the
provision of protective services to the President or others legally authorized.
Workers' Compensation: Your protected health information may be disclosed by us as authorized to
comply with workers' compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correc-
tional facility and your physician created or received your protected health information in the course
of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of Section 164.500 et.seq.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how
you may exercise these rights. You have the right to inspect and copy your protected health information. This means you
may inspect and obtain a copy of protected health information about you that is obtained in a designate record set for as
long as we maintain the protected health information. A "designated record set" contains medical and billing records and
any other records that your physician and the Gastrointestinal Group of North Jersey, P.A. uses for making decisions about
you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information com-
piled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected
health information that is subject to law that prohibits access to protected health information. Depending on the circum-
stances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision
reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right
to request a restriction of your protected health information. This means you may ask us not to use or disclose any part
of your protected health information for purposes of treatment, payment or healthcare operations. You may also request that
any part of your protected health information not be disclosed to family members or friends who may be involved in your
care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and
must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree
to your request. Your physician is not required to agree to a restriction that you may request. If the physician believes
it is in your best interest to permit use and disclosure of your protected health information, your protected health infor-
mation will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction unless it is needed to provide emergency treatment. With
this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by
providing a formal written statement to your physician with specific restrictions clearly identified. (To request restric-
tions, you must make your request in writing to your physician to the attention of our Privacy Official. In your request,
please include (1) the information that you want to restrict; (2) how you want to restrict the information (for example,
restricting use to this office, only restricting disclosure to persons outside this office, or restricting both); and
(3) to whom you want those restrictions to apply. You have the right to request to receive confidential communications
from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also con-
tion this accommodation by asking you for information as to how payment will be handled or specification of an alternative
address or other method of contact. We will not request an explanation from you as to the basis for the request. Please
make this request in writing to our Privacy Officer. (Example: you may want to be contacted by regular mail to your post
office box and not your home.) You have the right to have your physician amend your protected health information. This
means you may request an amendment of protected health information about you in a designated record set for as long as
we maintain this information. You must give us a reason for your request. In certain cases, we may deny your request for
an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and
we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. To make this type of
request you must submit your request in writing to our Privacy Official. Please contact our Privacy Officer to determine
if you have questions about amending your medical record. You have the right to receive an accounting of certain disclos-
ures we have made, if any, of your protected health information. This right applies to disclosures for purposes other
than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures
we may have made to you, for a facility directory, to family members or friends involved in your care, for notification
purposes (including national security, intelligence, correctional, and law enforcement purposes) and disclosures made
prior to April 14, 2003. You have the right to receive specific information regarding these disclosures that occurred
after April 14, 2003 and for a specified period of up to six years. You may request a shorter time frame. The right
to receive this information is subject to certain exceptions, restrictions and limitations. If you wish to make such a
request, please notify our Privacy Officer. The first list that you request in a 12-month period will be free, but we
may charge you for our reasonable costs of providing additional lists in the same 12-month period. We will tell you
about these costs, and you may choose to cancel your request at any time before costs are incurred. You have the right
to obtain a paper copy of this notice from us, upon request, and must sign for its receipt. To receive a copy please
contact our Privacy Official listed on the bottom of this page.
If you believe we have violated your rights, you may file a complaint with the Secretary of Health and Human Services or by
notifying our Privacy Officer at the address and telephone number listed below. We will not retaliate or take action against
you for filing a complaint.
If you have any questions about this Notice, please contact our Privacy Officer by calling 973-839-6400 or by mail
to the Gastrointestinal Group of North Jersey, P.A., 1777 Hamburg Turnpike, Suite 101, Wayne, NJ 07470.
THIS NOTICE WAS PUBLISHED PRIOR TO AND BECOMES EFFECTIVE ON APRIL 14, 2003.
A COPY OF THIS NOTICE WILL BE GIVEN TO A PATIENT UPON REQUEST
- Gastrointestinal Group of North Jersey, P.A.