Protecting patient privacy
North Shore-LIJ Health System holds the privacy of our patients’ health information as a core value. We respect our patients’ right to authorize the release of health information. We will only release personal health information with a valid authorization or when permitted by law. Federal and state laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provide guidance for patients regarding their privacy rights and the use or disclosure of their medical information. These rights are described in detail in North Shore-LIJ Health System’s Notice of Privacy Practices below.
To ensure the development of a lasting bond of trust with our patients, we have many safeguards to protect the privacy and security of your personal information. Each of our facilities has a Privacy Officer who is able to answer any questions a patient may have about the way in which their health information will be used. We also have many policies in place to protect the privacy and security of your personal information.
If you have any questions about your privacy rights or our policies in place to protect you, please contact the Office of Corporate Compliance at (516) 465-8097.
Q: What is HIPAA?
A: HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996, a federal law.
Q: What does HIPAA do?
A: HIPAA protects the privacy and security of patient medical information in both written and electronic forms. It also sets the terms on which medical information can be transmitted to other providers and to health insurers.
Q: Is the North Shore-LIJ Health System required to comply with HIPAA?
A: Yes. HIPAA applies to:
- Healthcare providers
- Health plans (self insured/insured, HMOs, health insurance companies, employer health plans, and similar arrangements)
- Healthcare clearinghouses (entities that standardize health information)
Q: What information is protected under HIPAA?
A: The HIPAA Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information "Protected Health Information,” which is also referred to as “PHI”. The following are examples of identifiers that could be considered individually identifiable information:
- Geographic subdivisions smaller than a state, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code in certain situations
- All elements of date (except year) for dates directly related to an individual, including birth date, discharge data, date of death; and all ages over 89 and all elements of dates indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older
- Telephone numbers
- Fax numbers
- Electronic mail addresses
- Social security numbers
- Medical record numbers
- Health plan beneficiary numbers
- Account numbers
- Certificate/license numbers
- Vehicle identifiers and serial numbers
- Medical device identifiers
- Web universal resource locators (URLs)
- Internet protocol (IP) address numbers
- Biometric identifiers, including finger and voice prints
- Full face photographic images and any comparable images
- Any other unique identifying number, characteristic, or code
Q: How is the North Shore-LIJ Health System ensuring compliance with HIPAA?
A: The Health System has implemented a number of controls to comply with HIPAA. Some of them are:
- Privacy Officers assigned to each of its facilities
- Regular, periodic training for the members of its workforce
- Policies and procedures to help protect the privacy and security of patients’ individually identifiable health information
- HIPAA-compliant forms to help implement HIPAA
- A Notice of Privacy Practices that is available to all patients
Q: What are the rights that HIPAA gives to me as a patient?
A: HIPAA provides many rights to patients. These rights include:
- The right to receive North Shore-LIJ Health System’s Notice of Privacy Practices
- The right to review and get a copy of your medical information
- The right to ask that your medical information be amended
- The right to ask for restrictions in the use of your health information
- The right to ask for confidential communications
- The right to an accounting of disclosures of your medical information
- The right to be notified if the privacy of your protected health information has been breached, as defined by HIPAA
- The right to file a complaint with North Shore-LIJ Health System or the U.S. Department of Health and Human Services’ Office for Civil Rights if you feel your privacy rights have been violated
Q: If I would like to request a copy of my medical record, what should I do?
A: You can access the form that you must fill out to request a copy of your medical records by clicking here. Submit the completed form to the individual who is responsible for medical records in the facility from which you are requesting the records.
Q: Will all of my information be included in the response to my request for medical information?
A: Most of the information in your medical record will be included in the response to your request. However, certain portions of your record, such as psychotherapy notes, may not be included in the response. For further information on this restriction, please click here.
Q: How do I request an amendment to my medical information?
A: You may request an amendment to your medical record if you believe that information in your l record is inaccurate. Subject to your health care provider’s discretion and applicable law, we will do our best to accommodate all reasonable requests. To request an amendment, please click on the following link to access the form you must complete and submit: Request for Amendment of Protected Health Information
Q: How do I request a restriction on the way in which my medical information is disclosed?
A: To request a restriction, please click on the following link to access the form you must complete and submit: Request for confidential Communications and/or Restrictions on Access, Use or Disclosure of Protected Health Information
Q: Who should I contact if I have more questions about my privacy rights?
A: North Shore-LIJ Health System has a staff of Compliance and Privacy Officers who are here to assist you with any questions related to the privacy of your health information. Please call the Office of Corporate Compliance at (516) 465-8097 for further information.
Q: Will my medical information be used for research purposes?
A: You may be asked to participate in research studies while you are a patient at North Shore-LIJ Health System facilities. However, your identifiable medical information will not be used for research purposes without your prior authorization.
Q: How can I learn more about HIPAA and patient privacy?
A: For more information about the privacy of your medical information, we recommend that you consult the following link: http://www.hhs.gov/ocr
Q: Who should I contact if I have a complaint related to the privacy of my medical information?
A: Please see the contact information section for details.
The North Shore-LIJ Health System’s Office of Corporate Compliance is here to address any question or complaint related to the way in which the privacy of medical information is handled. We can be reached as follows:Office of Corporate Compliance
200 Community Drive
Great Neck, NY 11021
Phone: (516) 465-8097
Fax: (516) 465-8996
Additionally, toll-free, anonymous, confidential, non-retaliatory reporting is available 24 hours, 7 days a week. Visit www.northshore-lij.ethicspoint.com or call (800) 894-3226.
While we hope you will contact North Shore-LIJ Office of Corporate Compliance first to address your concerns, you also have the right to contact the Office for Civil Rights to file a complaint.Office for Civil Rights
U.S. Department of Health and Human Services
Jacob Javits Federal Building
26 Federal Plaza - Suite 3312
New York, NY 10278
Voice Phone (212) 264-3313
FAX (212) 264-3039
TDD (212) 264-2355