The notice describes how medical information about you may be used and disclosed and how you can get access to this information.� Please review it carefully.

I.� Who We Are
This Notice describes the privacy practices of Warren Hospital, Warren Hills, Coventry Family Practice and the Roseberry Surgery Center and theirphysicians, nurses, and other personnel.� It applies to services furnished to you at Warren Hospital, Warren Hills, Coventry Family Practice, Roseberry Surgery Center and Hillcrest MSO (affiliate of Warren Health Services).

II.� Our Privacy Obligations
We are required by law to maintain the privacy of your health information (�Protected Health Information� or �PHI�) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information.� When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III.� Permissible Uses and Disclosures without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI.� However, we do not need any type of authorization from you for the following uses and disclosures:

�� � � � A.�Uses and Disclosures for Treatment, Payment and Health Care Operations.�We may use and disclose PHI (including, if any, your HIV/AIDS, venereal disease or tuberculosis information), in order to treat you, obtain payment for services provided to you and conduct our �health care operations� as detailed below:

�� � � Treatment.� We use and disclose your PHI to provide treatment and other services to you--for example, to diagnose and treat your injury or illness.� In addition, 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 also disclose PHI to other providers involved in your treatment.

�� � � Payment.� We may use and disclose your PHI to obtain payment for services that we provide to you--for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (�Your Payor�) to verify that Your Payor will pay for health care.

�� � � Health Care Operations.� We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you.� For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers.� We may disclose PHI to our Patient Relations Coordinator in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.

We may also disclose PHI to another health care facility to which you have been transferred when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.

�� � � � B. Use or Disclosure for Directory of Individuals in Warren Hospital.� We may include your name, location in Warren Hospital, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory or unless you are in the Behavioral Health Unit the identification of which would reveal that you are receiving treatment for Behavioral Health and therefore you will be excluded from the patient directory. �Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; however, religious affiliation will only be disclosed to members of the clergy.

�� � � � C. Disclosure to Relatives, Close Friends and Other Caregivers.� We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests.� If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person�s involvement with your health care or payment related to your health care.� We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

�� � � � D. Fundraising Communications.� We may contact you to request a tax-deductible contribution to support important activities of Warren Hospital.� In connection with any fundraising, we may disclose to Warren Hospital Foundation demographic information about you (e.g., your name and address) without your written authorization.� If youwish to make a tax-deductible contribution now or do not want to receive any fundraising requests in the future, you may contact the Warren Hospital Foundation at (908) 859-6789.

�� � � � E. Public Health Activities.� We may disclose your PHI for the following public health activities:�(1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities orother government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

�� � � � F. Victims of Abuse, Neglect or Domestic Violence.� If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.

�� � � � G. Health Oversight Activities.� We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

�� � � � H. Judicial and Administrative Proceedings.� We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process, such as, under New Jersey law, the request of a person (or his/her insurance carrier) against whom you have commenced a lawsuit for compensation or damages for your personal injuries.

�� � � � I. Law Enforcement Officials.� We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.

�� � � � J. Decedents.� We may disclose your PHI to a medical examiner as authorized by law.

�� � � � K. Organ and Tissue Procurement.� We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

�� � � � L. Research.� We may use or disclose your PHI without your consent or authorization if our Institutional Review Board approves a waiver of authorization for disclosure.

�� � � � M. Health or Safety.� We may use or disclose your PHI to prevent or lessen a threat of imminent, serious physical violence against you or another readily identifiable individual.

�� � � � N. Specialized Government Functions.� We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

�� � � � O. Workers� Compensation.� We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs.

�� � � � P. As required by law.� We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.

IV. Uses and Disclosures Requiring Your Written Authorization

�� � � � A. Use or Disclosure with Your Authorization.� For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on our authorization form (�Your Authorization�).� For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.

�� � � � B. Marketing.� We must also obtain your written authorization prior to using your PHI to send you any marketing materials.� (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining Your Marketing Authorization.� We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.)�In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

�� � � � C. HIV/AIDS Related Information.� Your Authorization must expressly refer to your HIV/AIDS related information in order to permit us to disclose your HIV/AIDS related information.�However, there are certain purposes for which we may disclose your HIV/AIDS information, without obtaining Your Authorization:� (1) your diagnosis and treatment; (2) scientific research; (3) management audits, financial audits or program evaluation; (4) medical education; (5) disease prevention and control when permitted by the New Jersey Department of Health and Senior Services; (6) to comply with a certain type of court order; and (7) when required by law, to the Department of Health and Senior Services or another entity.� You also should note that we may disclose your HIV/AIDS related information to third party payors (such as your insurance company or HMO) in order to receive payment for the services we provide to you.

�� � � � D. Genetic Information.� Except in certain cases (such as a paternity test for a court proceeding, anonymous research, newborn screening requirements, or pursuant to a court order), we will obtain your special written consent prior to obtaining or retaining your genetic information (for example, your DNA sample), or using or disclosing your genetic information for treatment, payment or health care operations purposes.� We may use or disclose your genetic information for any other reason only when Your Authorization expressly refers to your genetic information or when disclosure is permitted under New Jersey State law including, for example, when disclosure is necessary for the purposes of a criminal investigation, to determine paternity, newborn screening, identifying your body or as otherwise authorized by a court order.

�� � � � E. Venereal Disease Information.� Your Authorization must expressly refer to your venereal disease information in order to permit us to disclose any information identifying you as having or being suspected of having a venereal disease.� However, there are certain purposes for which we may disclose your venereal disease information, without obtaining Your Authorization, including to a prosecuting officer or the court if you are being prosecuted under New Jersey law, to the Department of Health and Senior Services, or to your physician or a health authority, such as the local board of health.� Your physician or a health authority may further disclose your venereal disease information if he/she/it deems it necessary in order to protect the health or welfare of you, your family or the public.�Under New Jersey law, we may also grant access to your venereal disease information upon the request of a person (or his/her insurance carrier) against whom you have commenced a lawsuit for compensation or damages for your personal injuries.

�� � � � F. Tuberculosis Information.� Your Authorization must expressly refer to your tuberculosis information in order to permit us to disclose any information identifying you as having tuberculosis or refusing/failing to submit to a tuberculosis test if you are suspected of having tuberculosis or are in close contact to a person with tuberculosis.�However, there are certain purposes for which we may disclose your tuberculosis information, without obtaining Your Authorization, including for research purposes under certain conditions, pursuant to a valid court order, or when the Commissioner of the Department of Health and Senior Services (or his/her designee) determines that such disclosure is necessary to enforce public health laws or to protect the life or health of a named person.

�� � � � G. Psychotherapy Notes.� Your authorization must expressly refer to your psychotherapy notes in order to permit us to disclose them, except under certain circumstances, for example; for treatment, payment, operations, defense in legal actions and education.

V. Your Rights Regarding Your Protected Health Information

�� � � � A.� For Further Information; Complaints.� If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Officer.� You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services.�Upon request, the Privacy Officer will provide you with the correct address for the Director.� We will not retaliate against you if you file a complaint with us or the Director.

�� � � � B. Right to Request Additional Restrictions.� You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.� While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. Notify the Privacy Officer or the Director of Health Information Management or send your written request for additional restrictions to the Health Information Management Department.� We will send you a written response.

�� � � � C. Right to Receive Confidential Communications.� You may request, and we will accommodate, any reasonable writtenrequest for you to receive your PHI by alternative means of communication or at alternative locations.

�� � � � D. Right to Revoke Your Authorization.� You may revoke Your Authorization or Your Marketing Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified below or the Director of the Health Information Management Department.

�� � � � E. Right to Inspect and Copy Your Health Information.� You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.� Under limited circumstances, we may deny you access to a portion of your records.� If you desire access to your records, please obtain a record request form from the Health Information Management Department and submit the completed form to the Health Information Management Department.�If you request copies, we will charge you $1.00 per page -- for the first 100 pages, and $0.25 per page after that -- up to a maximum of $200.00 per record.� We will also charge you for our postage costs, if you request that we mail the copies to you.

You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor�s medical record will not be accessible to you (for example, records relating to pregnancy, abortion, sexually transmitted diseases, substance use or abuse, or contraception and/or family planning services).

�� � � � F. Right to Amend Your Records.� You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records.� If you desire to amend your records, please obtain an amendment request form from the Health Information Management Department and submit the completed form to the Health Information Management Department.�We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

�� � � � G. Right to Receive an Accounting of Disclosures.� Upon written request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you [$1.00 per page] of the accounting statement.

�� � � � H. Right to Receive Paper Copy of this Notice.� Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

�� � � � � A. Effective Date.� This Notice is effective on April 14, 2003.

�� � � � B. Right to Change Terms of this Notice.� We may change the terms of this Notice at any time.� If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice.�If we change this Notice, we will post the new notice in waiting areas around Warren Hospital and on our Internet site at www.WarrenHospital.org.� You also may obtain any new notice by contacting the Privacy Officer.

VII.����� Privacy Office

You may contact the Privacy Officer at:
�� � � � Barbara A. Balas
�� � � � Warren Hospital
�� � � � 185 Roseberry Street
�� � � � Phillipsburg, NJ� 08865

Telephone Number: 908-859-6749��

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