New Jersey Department of Military and Veterans Affairs
Veterans Healthcare Services



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Understanding Your Health Record Information

Each time you visit a hospital, physician, or other healthcare provider, the provider makes a record of your visit. Typically, this record contains your health, mental and social history, current symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your 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 you actually received the services billed you
  • A tool in medical education
  • A source of information for public health officials charged with improving the health of the regions they serve
  • A tool to assess the appropriateness and quality of care you received
  • A tool to improve the quality of healthcare and achieve better patient outcomes
  • A source of information for certifying and regulatory agencies
Understanding What Is In Your Health Records And How Your Health Information Is Used Helps You To:
  • Ensure its accuracy and completeness
  • Understand who, what, where, why, and how others may access your health information
  • Make an informed decision about authorizing disclosure to others
  • Better understand the health information rights detailed below
  • Better participate in the management of your own healthcare
Your Rights Under The Federal Privacy Standard:

Although your records are the physical property of the healthcare provider who completed it, you have certain rights with regard to the information contained therein. You have the right to:

  • Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. "Health care operations" consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. We do not, however, have to agree to the restriction. If we do, however, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means and, if the method of communication is reasonable, we must grant the alternate communication not requiring an authorization communication request. The right to request restriction does not extend to uses or disclosures permitted or required under xx 164.502(a)(2)(I) (disclosures to you), 164.510(a) (for facility directories, but note that you have the right to object to such uses), or 164.512 (uses and disclosures not requiring an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory communicable disease reporting. In those cases, you do not have a right to request restriction.
  • Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.
  • Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
    • Psychotherapy notes. Such notes comprise those that are recorded in any medium by a healthcare provider who is a mental health professional documenting or analyzing a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record.
    • Information compiled in a reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
    • Protected Health Information (PHI), that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C x 263A, to the extent that the provision of access to the individual would be prohibited by law.
    • Information that was obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.
        In other situations, the provider may deny you access but, if it does, the provider must provideyou with a review of the decision denying access. These "reviewable" grounds for denial include:
    • Licensed healthcare professionals have determined, in the exercise of professional judgement, that the access is reasonably likely to endanger the life or physical safety of the individual or another person.
    • PHI makes reference to another person (other than a healthcare provider) and a licensed healthcare provider has determined, in the exercise of professional judgement, that the access is reasonably likely to cause substantial harm to such other person.
    • The request is made by the individual’s personal representative and a licensed healthcare professional has determined, in the exercise of professional judgement, that the provision of access to said personal representative is reasonably likely to cause substantial harm to the individual or another person.
    • For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review.
  • If we grant access, we will tell you what, if anything, you have to do to get access.

(We Reserve The Right To Charge A Reasonable, Cost-Based Fee For Making Copies)

  • Request amendment/correction of your health information. We do not have to grant the request if:
    • We did not create the record. If, as in the case of a consultation report from another provider we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record (s). If they amend or correct the record, we will put the corrected record in our records.

    • The records are not available to you as discussed immediately above.

    • The record is accurate and complete

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those you identify to us that you want to receive the corrected information.

  • Obtain an accounting of "non-routine" uses and disclosures-(those other than for treatment payment, and health care operations) to individuals regarding your protected health information. We do not need to provide an accounting for:
    • The facility directory or to persons involved in the individual’s care or other notification purposes as provided in x 164.510 (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for the care of the individual, of the individual’s location, general condition, or death).
    • National safety or intelligence purposes under x 1640512(k))(2) (disclosures not requiring consent, authorization, or an opportunity to object.)
    • To correctional institutions or law enforcement officials under 164.512(k)(5) (disclosures not requiring consent, authorization, or an opportunity to object).
    • That which occurred before April 14, 2003.
    • We must provide the accounting within 60 days. The accounting must include:
      • Date of each disclosure.
      • Name and address of the organization or person who received the protected health information.
      • Brief description of the information disclosed.
      • Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of the written request for disclosure.
    The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.
  • Revoke your authorization to use or disclose health information except to the extent that we have already taken action in reliance on the authorization.

Our Responsibility Under The Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standards requires us to:

      • Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.

      • Provide you with this notice as to our legal duties and privacy practices with respect to individually identifiable health information we collect and maintain about you.

      • Abide by the terms of this notice.

      • Train our personnel concerning privacy and confidentiality.

      • Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies with regard thereto.

      • Mitigate (lessen the harm of) any breach of privacy/confidentiality.


We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

How To Get More Information Or To Report A Problem

If you have questions and/or would like additional information, you may contact the privacy officer at (201) 967-7676 ext. 369.

Examples Of Disclosures For Treatment, Payment, And Health Operations

"We Will Use Your Health Information For Treatment"

Example: A physician, nurse, or other member of your healthcare team will record information in your record to diagnose your condition and determine the best course of treatment for you. The primary caregiver will give treatment orders and document what he or she expects other members of the healthcare team to do to treat you. Those other members will then document the actions they took and their observations. In that way, the primary caregiver will know how you are responding to treatment.

We will also provide your physician, other healthcare professionals, or subsequent healthcare provider with copies of your records to assist them in treating you once we are no longer treating you.

"We Will Use Your Health Information For Payment"

Example: We may send a bill to you or to a third-party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received, and supplies used.

"We Will Use Your Health Information For Health Operations"

Examples: Members of the medical staff, the risk or quality improvement manager, or membersof the quality assurance team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.

Business associates: We provide some services through contracts with business associates. Examples include certain diagnostic tests, rehabilitation services, transportation services and pharmacy services. When we use these services, we may disclose your health information to the business associate so they can perform the function (s) we have contracted with them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and/or veterans organizations for the purpose of providing you with the benefit of their volunteer services, and except for religious affiliation, to other people who ask for you by name.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication With Family: Unless you object, health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant in your care, or payment related to your care.

Research: We may disclose 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 health information, and you have consented to such research.

Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to enable them to carry out their duties.

Marketing Continuity Of Care: 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.

Fund-Raising: We may contact you as part of a fund-raising effort. You have the right to request not to receive subsequent fund-raising materials.

Facility Activities: We may include your name, biography, birthday, picture or other information as part of our Resident Newsletter or Volunteer or Activities Program. Your name may be posted on a facility trip list for a trip you requested.

Food and Drug Administration (FDA): We may disclose to the FDA, health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or posting marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: 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: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose health information as required by law or in response to a valid subpeona.

Health Oversight Agencies And Public Health Authorities: If a member of our work force or a business associate believes, in good faith, that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and potentially endangered one or more patients, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the Department of Health, and Senior Services, and other public health agencies.

The Department of Health and Senior Services (DHSS) and the Veterans Administration (VA):
Under the Privacy standards, we must disclose your health information to DHSS, and the Veterans Administration, as necessary for them to determine our compliance with those standards.


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