Pittsburgh Mercy Notice of Privacy Practices

Your Privacy Matters

Updated June 16, 2021

This notice describes how health information about you may be used and disclosed by Pittsburgh Mercy Health System (Pittsburgh Mercy), and how you can get access to this information. Please review it carefully.

If you have any questions about this notice, please contact Pittsburgh Mercy by phone or in writing at:

Compliance, Integrity, & Risk Officer
Pittsburgh Mercy
1200 Reedsdale Street, Third Floor
Pittsburgh, PA 15233-2109
1-877-637-2924.

We create a record of the care and services you receive at Pittsburgh Mercy to provide you with quality care and to comply with certain legal requirements. This notice tells you about the possible ways in which we may use and disclose your health information from this record.

We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Health Information Technology for Economic and Clinical Health (HITECH) Act, found in Title XII of the American Recovery and Reinvestment Act of 2009, collectively referred to as “HIPAA” laws, to:

  • Make sure that health information that identifies you is kept private
  • Give you this notice of our legal duties and privacy practices with respect to health information about you, and
  • Follow the terms of the notice that is currently in effect.

Please read this Notice of Privacy Practices thoroughly. It describes how we will use and protect your health information, your rights, and certain obligations we have regarding the use and disclosure of health information.

Our Pledge Regarding Your Health Information

Any information you share with staff and programs of Pittsburgh Mercy is important to us, and we pledge to keep it as confidential as possible. This rule applies to all employees, programs, and services operated by Pittsburgh Mercy including, but not limited to: Bethlehem Haven, Pittsburgh Mercy Behavioral Health, Pittsburgh Mercy Community Health, Pittsburgh Mercy Intellectual Disabilities Services, Pittsburgh Mercy Parish Nurse & Health Ministry Program, Pittsburgh Mercy’s Operation Safety Net®, and Pittsburgh Mercy Family Health Center.

By law, there are some exceptions to this rule. The exceptions are listed below. With the exception of these items, we pledge to maintain maximum confidentiality. Any releases of information permitted by HIPAA which are prohibited by federal and state regulations and laws continue to be prohibited.

Permitted Uses & Disclosures

Exception 1: To Improve the Quality of Your Treatment

We may use health information about you to provide you with other clinical or health services. We may disclose health information about you to doctors, nurses, therapists, staff, or others who are involved in taking care of you at Pittsburgh Mercy. For example, if you are referred to another program within Pittsburgh Mercy, your new provider and/or support staff will know about your needs and goals without having to ask you to repeat your story.

We may also disclose health information about you to physicians, other practitioners and providers, Pittsburgh Mercy affiliates, and other health care facilities outside Pittsburgh Mercy for their use in treating you. In Pennsylvania, the laws protecting information regarding substance abuse treatment are more stringent. We will limit access to your data in keeping with those laws.

Exception 2: To Improve the Internal Operations of Our Organization

We may use and disclose clinical or identifying information about you to improve internal operations. These uses and disclosures are necessary to run the organization and ensure that all of the individuals we serve receive quality care. For example, we may use information to review our treatment and services and to evaluate the performance of our staff and programs in caring for you. We may also provide minimal information to support staff to assist in answering your calls, scheduling appointments, and in directing you to the staff and services you need. We may contact you as a reminder that you have an appointment for treatment or health services.

Additionally, we may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. We also believe that friends or family members may be helpful to you in reaching your goals. Where you indicate to us in writing that you want them to have access to information, we will talk to them and release information as authorized. Only persons you indicate will have this type of access.

Exception 3: To Your Insurance or Responsible Party to Receive Payment

Medicaid or your insurance carrier will need to know some basic details about your condition and the services provided. Worker’s Compensation and military insurances may have special needs for information. This information is limited by state and federal laws, and we will provide them the minimal necessary information when we receive your written approval at the time of admission to bill your insurer and provide this information.

Exception 4: To Our Business Associates

We may disclose your health information to our business associates and allow them to create, use, and disclose your health information to perform their job. For example, we may disclose your health information to an outside billing company that assists us in billing insurance companies. As a member of Trinity Health, a national health care system, we may share information for utilization and quality assessment activities with Trinity Health and other members of the health system as appropriate. Trinity Health and Pittsburgh Mercy will abide by the terms of this Notice of Privacy Practice in using information for treatment, payment, and operations. If you would like a listing of member organizations, please contact the Pittsburgh Mercy Compliance, Integrity, and Risk Officer.

Exception 5: Where There Is a Serious Threat to Health or Safety

We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Exception 6: As Required By Law

We will disclose health information about you when required to do so by federal, state, or local laws. For example, if you are involved in a lawsuit or a legal dispute, we may disclose health information about you in response to a court or administrative order, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

We may release health information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons, or similar process
  • To identify or locate a suspect, fugitive, material witness, or missing person
  • About the victim of a crime, if, under certain limited circumstances, we are unable to obtain the person’s agreement
  • About a death we believe may be the result of criminal conduct
  • About criminal conduct at Pittsburgh Mercy
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime. Also, we may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • To identify a deceased person or to determine a cause of death, we may disclose information to a coroner, medical examiner, and funeral directors (as necessary to carry out their duties).
  • We may identify you by name and location in any of our mental health or primary care facilities in accordance with federal, state, and local laws. In Pennsylvania, laws governing substance abuse treatment facilities may not permit this disclosure, and we will adhere to those laws in those facilities.

Exception 7: As Required By Law for Public Health Activities

The law also requires us to disclose health information about you for public health activities. These activities generally include prevention or control of disease, injury, or disability; reporting deaths; reducing reactions to medications or problems with products; notifying people of recalls of products they may be using; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Additionally, we may disclose proof of immunizations to a school where Pennsylvania or other similar law requires it prior to admitting a student.

Exception 8: As Required By Law for Victims of Abuse or Neglect

We may disclose your health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, if we believe that you have been a victim of abuse, neglect, or domestic violence, we may disclose your health information to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Exception 9: For Research, Under Certain Circumstances

Under certain circumstances, we may use or disclose your health information for research, subject to certain safeguards. For example, we may disclose information to researchers when their research has been approved by a special committee that has to review the research proposal and established protocols to ensure the privacy of your health information. We may disclose health information about you to people preparing to conduct a research project; however, the information will stay on site.

Exception 10: Health Information Exchange

Pittsburgh Mercy may share your health records electronically with the local Health Information Exchange (HIE) for the purpose of improving the overall quality of health care services provided to you (such as avoiding unnecessary duplicate testing). The HIE functions as our business associate and, in acting on our behalf, the HIE will transmit, maintain, and store your health information for treatment, payment, and health care operations purposes. The HIE has a duty to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your health information.

Exception 11: Other Uses & Disclosures

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless otherwise required by law. For example, we may disclose your health information for certain Pittsburgh Mercy fundraising activities. We may also use and disclose health information for certain health promotion activities. For example, your name and address may be used to send you a general newsletter or specific information based on your own health concerns.

However, any fundraising or health promotion communication sent to you will let you know how you can exercise your right to opt out of receiving similar communications in the future.

Exception 12: Uses & Disclosures Requiring Permission

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. For example, subject to certain limited exceptions, your written permission is required in any circumstance where Pittsburgh Mercy may receive direct or indirect payment in exchange for making the communication to you which encourages you to purchase a product or services or for a disclosure to a third party who wants to market products or services to you. Your written permission is required for any sale of health information. Most uses and disclosures of psychotherapy notes require your written permission as well.

If you provide us with permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Your Rights Regarding Health Information About You

You have the following rights regarding health information we maintain about you:

Right to Inspect & Copy

You have the right to inspect and copy health information that may be used to make decisions about your care. This usually includes health and billing records; however, it does not include psychotherapy notes and other mental health records under certain circumstances.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to:

Health Information Management Department Manager
Pittsburgh Mercy
1200 Reedsdale Street, Third Floor
Pittsburgh, PA 15233-2109.

If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you agree, we may provide you with a summary of the information instead of a copy of your entire record or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay the fees, if any, for preparing the summary or explanation.

We may deny your request to inspect and copy your health information in certain, very limited circumstances. The project, facility, or clinical director may temporarily remove portions of the records prior to your inspection if the director determines that the information may be detrimental if presented to you. Reasons for removing sections will be documented in the record. Additionally, a physician may determine that for health reasons, this is not advisable. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the organization will review your request and the denial. The person conducting the review will not be the person who denied your request. We will do what this person decides.

Right to Amend

If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Pittsburgh Mercy.

To request an amendment, send your request in writing to:

Health Information Management Department Manager
Pittsburgh Mercy
1200 Reedsdale Street, Third Floor
Pittsburgh, PA 15233-2109.

You must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created it is no longer available to make the amendment
  • Is not part of the health information kept by or for Pittsburgh Mercy
  • Is not part of the information which you would be permitted to inspect or copy, or
  • Is accurate and complete.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of some of the disclosures of health information about you that we made that were not specifically authorized by you in advance with the exception of the following disclosures:

  • For treatment, payment, and operations
  • To persons involved in your care
  • For national security or intelligence purposes, or
  • To correctional institutions or law enforcement officials.

Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (I.e., on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved. You may choose to withdraw or modify your request at that time, before any costs are incurred.

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limitation on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, then we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, you must make your request in writing. In your request, you must tell us:

  • What information you want to limit
  • Whether you want to limit our use, disclosure, or both, and
  • To whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Restrictions to a Health Plan

You have the right to request a restriction on disclosures of your health information to a health plan (for purposes of payment or health care operations) in cases where you have paid out of pocket, in full, for items received or serviced rendered by Pittsburgh Mercy.

Right to Confidential Communications

You have the right to request to receive communications from us by using alternative means for receipt of information or by receiving the information at alternative locations. We must accommodate your request, if it is reasonable. Contact the Pittsburgh Mercy Compliance, Integrity, and Risk Officer if you require such confidential communications.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice even if you received a copy electronically. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, request a copy from the Health Information Management Department at 412-320-2380.

Breach of Unsecured Information

If a breach of unsecured health information affecting you occurs, Pittsburgh Mercy is required to notify you of the breach in writing and to indicate any and all remedies and corrective actions taken to respond to the breach.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the organization as well as on our website, www.pittsburghmercy.org. The effective date of this notice will be published at the top of the first page of the print document as well as at the top of the web page titled Pittsburgh Mercy Notice of Privacy Practices.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Pittsburgh Mercy or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Pittsburgh Mercy, contact:

Compliance, Integrity, and Risk Officer
Pittsburgh Mercy
1200 Reedsdale Street, Third Floor
Pittsburgh, PA 15233-2109

Complaints must be submitted in writing. You will not be penalized for filing a complaint.

If You Have Questions About This Notice

If you have questions about the Pittsburgh Mercy Notice of Privacy Practices, contact your therapist, the Pittsburgh Mercy Compliance, Integrity, and Risk Officer at 1-877-637-2924, or write to:

Compliance, Integrity, and Risk Officer
Pittsburgh Mercy
1200 Reedsdale Street, Third Floor
Pittsburgh, PA 15233-2109.

Page Updated: June 16, 2021

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