Updated 6/12/2018
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC www.meridianpediatricsurgery.com
Directions to Eatontown Office
Route 18 (North or South) Take to exit 13B-Route 36 East
Travel 1 mile to 3rd
light and make right onto Route 35 S
Travel almost 1 mile to 2nd
traffic light and make a right on Industrial Way West
Turn into 1st driveway on right (Meridian Center 2/4/6)
Make 2
nd right
Our building at 4 Industrial Way West is directly in front of you.
Make left and park on the side of building in one of our convenient parking spots.
Access through glass front doors past bench.
Garden State Parkway Coming from the South Take GSP Exit 105
Follow signs for Route 36 East
Take Route 36 East 1.5 and make right at 3rd
light-Route 35 South
Follow directions from above
Garden State Parkway Coming from the North Take GSP Exit 105
Take route 36 East 1.5 and make right at 3rd
light-Route 35 South
Follow directions from above
***FYI, we are on the opposite side of Industrial Way from Homewood Suites by Hilton***
Victoriya Staab, M.D.
Christine M. Williams, PA-C
4 Industrial Way West, Suite 100,Eatontown,NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
Updated 6/12/2018
Hackensack Meridian Pediatric Surgical Associates, PC (As a safeguard for your privacy, DO NOT e-mail these forms back to us. However, you may fax
them back to us to our secure fax #732-935-0757, if this is convenient for you.)
The following is the “patient information” forms that we require. Please fill out these
forms in their entirety and bring them with you for your appointment along with your
insurance card(s) and parent/guardian must have a photo ID. If you are not the
biological parent, please bring proof of legal guardianship. We cannot treat your child
without it. If your child is 18 years of age or older, please make sure they also bring
their ID.
Please fill in both “legal” parents information on the attached forms.
Without it, we cannot release any health information to them.
Please be aware, we also need a script from your child’s pediatrician requesting the
consultation with our doctor(s). It must state the reason for the consultation. If your
insurance company mandates the use of a referral form, that form will be sufficient.
Due to the nature of the specialty as pediatric surgeon, we may experience the need to
insert emergency appointments during our regularly-scheduled appointment times. We
do not anticipate a long wait, but in order for the doctor to give each patient the time
and attention required, you might experience a longer wait time. We do our best to
avoid this from occurring and would greatly appreciate your patience and understanding
if this should occur. Our goal is to have your child seen within 1 hour of their
scheduled appointment time, but usually it is much sooner.
We strive to provide the
“Best Health Care Experience”.
Please let us know how we are doing.
After your visit with our doctor, you may receive a survey through
your email. If there is no response is received, or you do not have an
email, you may get an automated call. Please take the time to
complete the survey for us.
Thank you. --The Staff at Hackensack Meridian Pediatric Surgical Associates, PC
Updated 6/12/2018
PEDIATRIC PATIENT REGISTRATION- PERSONAL INFORMATION
Patient’s Name:
1. _____________________________________________ DOB ___________________Sex: Male Female (Circle One)
2. _____________________________________________ DOB ___________________Sex: Male Female (Circle One)
*What is the reason for today’s visit? ______________________________________________________________________
*Name of Pediatrician: _________________________________Town: _______________________ Tel#________________
Did they refer you to us? _____________________ If not, who did? ____________________________________________
Language spoken at home: ___________________ Pharmacy name & phone: _____________________________________
Race: American Indian/Alaska Native Asian Black/African American
Native Hawaiian /Other Pacific Islander White Choose not to answer
Ethnicity: Hispanic/Latino Not Hispanic/Latino Choose not to answer
Parent/Guardian: _____________________________DOB: ___________Relationship to patient(s): ___________________
Home Address: (Street) _____________________________________ (City/State) _______________________ (Zip) ________
Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home
Preferred Method of Contact (please circle): Phone US mail Email via secure portal
Email Address: _____________________________________ Employer: __________________________________________
Parent/Guardian: ___________________________DOB: ___________Relationship to patient(s): _____________________
Home Address: (Street) ______________________________________ (City/State) ______________________ (Zip) ________
Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home
Email Address: _____________________________________ Employer: __________________________________________
Emergency Contact: ____________________________Phone:_____________________Relationship:____________________
INSURANCE INFORMATION
Primary Insurance Co. Information: (name, address and phone # of person responsible for payment)
Insurance Company Name: _____________________________________________Phone: ___________________________
Policy/ID Number: ____________________________Group #: __________________ Effective Date: __________________
Subscriber’s Name: _____________________________________ Relationship to Patient____________________________
Subscriber’s DOB: _______________
Ins. Address: __________________________________________________________________________________________
Secondary Insurance Co. Information: (name, address and phone # of person responsible for payment)
Insurance Company Name: ______________________________________________ Phone: ___________________________
Policy/ID Number: _____________________________ Group #: ________________ Effective Date: ____________________
Subscriber’s Name: _______________________________________ Relationship to Patient____________________________
Subscriber’s DOB: ____________________
Ins. Address: ___________________________________________________________________________________________
Signature: _______________________________________________________________ Date: ______________________
Hackensack Meridian Pediatric Surgical Associates
Updated 6/12/2018
BARRIER TO CARE:
State of New Jersey mandates that every physician documents any barrier to care including cultural
and linguistic needs in the medical record. Factors affecting care are visual or auditory factors
which may impede your ability to comprehend medical discussion and language, cultural and/or
religious customs, which may impact the provider’s ability to provide medical care. Addressing
these needs will improve patient satisfaction and also decrease health care disparities.
Do you have any Impairment – (i.e. Visual, hearing, speech, learning, physical and language/cultural
barrier) _______________________________________________________________________
What language do you speak, read or write? __________________________________________
Do you have any religious or culture customs that the doctor should know about?
Yes No ____________________________________________________
Patient’s Name: _____________________________________ DOB: __________________
Legal Guardian’s Signature: __________________________________________________
Relationship________________________________________________________________
Date: ______________________________________________________________________
*****Laboratory and Radiology Services*****
We have our testing done at Jersey Shore University Medical Center, as we can obtain your
child’s results faster and our doctor has constant communication with the radiologists.
However, if your insurance requires you to use a specific facility please let us know.
Which laboratory facility do you use? LabCorp Quest Other: _____________________
Which facility do you use for imaging studies? _______________________________________
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC
Victoriya Staab, M.D.
Christine M. Williams, PA- C
4 Industrial Way West Suite 100, Eatontown, NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
www.meridianpediatricsurgery.com
Updated 6/12/2018
PERMISSION TO RECEIVE PRERECORDED MESSAGES AND/OR TEXT MESSAGES
As a service to our patients, we provide courtesy appointment reminder calls and when we can text messages. We also
may place other important calls and send text messages using a prerecorded or automated message. In order to authorize
receiving the calls and messages, please fill out the information below and provide the phone number where you wish to
receive these messages.
Important note: By providing your cell phone number below, you consent to receiving appointment reminder calls,
important calls and/or text messages on your cell phone. If you would like us to utilize a different number—please provide
that number below instead of your cell phone number.
This authorization permits us to leave messages, call or text you on the phone number that you provide below. If you
provide your cell phone number, you will receive automated or prerecorded messages on your cell phone. We are required
by law to advise you of this.
You do not need to sign this authorization; however, - if you do not sign this authorization, we will not be able to provide
you with courtesy reminder calls, text messages or other important calls.
Patient Name __________________________________ Patient date of birth: ______________
Legal Guardian if a minor: __________________________________Relationship: ______________
Signature of Parent or Legal Guardian _______________________________ (if patient is a minor)
Phone number authorized by Patient to receive calls and message as set forth above:
Cell Phone Number: __________________________
Telephone Number: __________________________
Date_____________________
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC
Victoriya Staab, M.D.
Christine M. Williams, PA- C
4 Industrial Way West Suite 100, Eatontown, NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
www.meridianpediatricsurgery.com
Updated 6/12/2018
Patient’s Name: ___________________________________ Date of Birth: ____________
Payment Policy
We are committed to providing you with quality and affordable health care. Some of our patients
have questions regarding patient and insurance responsibility for services rendered, so we’ve
developed this payment policy. Please read it, ask us any questions you may have, and sign in the
space provided. A copy will be provided to you upon request.
1. Insurance. If you are not insured by a plan we do business with, payment in full is expected at
each visit or with-in 14 days of the billing statement. If you are insured by a plan we do business
with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we
can verify your coverage or with-in 14 days of the billing statement. Knowing your insurance
benefits is your responsibility. Please contact your insurance company with any questions you may
have regarding your coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of
service. This arrangement is part of your contract with your insurance company. Failure on our part
to collect co-payments and deductibles from patients can be considered fraud. Please help us in
upholding the law by paying your co-payment at each visit.
3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive
may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You
must pay for these services at time of service or with-in 14 days of billing statement.
4. Proof of insurance. All patients must complete our patient information form before seeing the
doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of
insurance. If you fail to provide us with the correct insurance information in a timely manner, you
may be responsible for the balance of a claim.
5. Claims submission. We will submit your claims and assist you in any way we reasonably can to
help get your claims paid. Your insurance company may need you to supply certain information
directly. It is your responsibility to comply with their request. Please be aware that the balance of
your claim is your responsibility whether or not your insurance company pays your claim. Your
insurance benefit is a contract between you and your insurance company; we are not party to that
contract.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can
make the appropriate changes to help you receive your maximum benefits. If your insurance
company does not pay your claim in 60 days, the balance will automatically be billed to you.
Initial ______________
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC
Victoriya Staab, M.D.
Christine M. Williams, PA- C
4 Industrial Way West Suite 100, Eatontown, NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
www.meridianpediatricsurgery.com
Updated 6/12/2018
7. Nonpayment. Partial payments will not be accepted unless otherwise negotiated. Please be aware
that if a balance remains unpaid, we may refer your account to a collection agency authorized to credit
report all outstanding debts to the four major National Credit Agencies, litigate in a court of law (other
legal fees my apply) and charge a service fee of 30% of the outstanding balance in the event that we
incur additional pre-collection and collection fees to reach a final resolution of any outstanding
balance for which you owe the practice.
8. Additional Cost of Collection Services. Invoices shall be deemed to be accepted by you unless Meridian Pediatric Surgical Associates, PC is notified in writing within 14 days of the invoice being issued that you dispute the amount of the invoice. In the event of non-payment, Hackensack Meridian Pediatric Surgical Associates, PC may in addition to the invoice amount charge:
(i.) Interest on any outstanding amounts from the due date calculated at the statutory penalty rate of 16%. (ii) Legal and debt collection fees incurred by Hackensack Meridian Pediatric Surgical Associates, PC in relation to recovery of outstanding amounts.
Where any part of your medical account with Hackensack Meridian Pediatric Surgical Associates, PC has fallen into arrears then the totality of that account whether or not in arrears shall become immediately due and payable.
9. Missed appointments. Our policy is to charge $30 for missed appointments not cancelled within
24 business hours. These charges will be your responsibility and billed directly to you. Please help us
to serve you better by keeping your regularly scheduled appointment or call 24 hours prior to cancel
your scheduled appointment.
Our practice is committed to providing the best treatment to our patients.
Our prices are representative of the usual and customary charges for our area.
Thank you for understanding our payment policy.
Please let us know if you have any questions or concerns.
I have read and understand the payment policy and agree to abide by its guidelines:
_____________________________________________ ______________________
Signature of patient or responsible party Date
Patient’s Name: _______________________________________ Date of Birth: _____________
Updated 6/12/2018
CONSENT FOR TREATMENT:
I acknowledge that I have elected on my own behalf or on behalf of my dependent to receive
medical services that may or may not be covered by my health plan or any number of reasons.
I understand and acknowledge that I am financially responsible for, and therefore shall pay for, all
services rendered to me or my dependent that are not paid or contractually adjusted by my insurance,
in whole or in part, by my health plan for any reason whatsoever.
RELEASE OF INFORMATION:
I authorize the release of all information necessary to process my insurance claims and pertinent to
my medical care. This release will remain in effect until revoked by me in writing. A photocopy of
this release is to be considered as valid as the original.
ASSIGNMENT OF BENEFITS:
I assign all medical and/or surgical benefits including major medical benefits to which I am entitled,
including Medicare, BCBS, HMO plans, and commercial insurance to (insert practice name) This
assignment will remain in effect until revoked by me in writing. I hereby authorize the above to
release information to secure payment on my behalf.
I understand that I am financially responsible for all charges. I have read this information and
understand it.
Patient Name: _______________________________ DOB: _________________________
Signature of Parent or Guardian: _______________________________________________
(If patient is a minor.)
Signature: ___________________________________________________________________
Date: ___________________________________
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC
Victoriya Staab, M.D.
Christine M. Williams, PA- C
4 Industrial Way West Suite 100, Eatontown, NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
www.meridianpediatricsurgery.com
Updated 6/12/2018
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES
Patient Name: ____________________________________ Date of Birth: __________ Age: ___________ Sex: Male Female
Weight at birth? _________ Hospital: __________Country? ________ Full term? Yes / No born @______gestation Vaginal/ C-Section
Is child a multiple? Yes No , If Yes, (twin) (triplet) (quadruplet) Birth Order: ___ Conceived by In-Vitro Fertilization? Yes No
Apnea Monitor: Currently being used or was it used? If yes, When? ___________ When was it stopped? ________________
Male Patient: Circumcised: Y N - If yes, Date: _____________________ Hospital: ________________________________
Female patient: Menstruating: Y N Onset _________________________ Last ______________________________________
Current Medications: (Including Vitamins, Over the Counter, Herbs etc.)
Medication Condition Being Treated
Does your child have any ALLERGIES: Please Answer Each Question (Circle Answer)
Type of Allergy: (Circle Answer) Reaction Type
Shellfish Yes No
Latex Yes No
Anesthesia Yes No
Surgical Adhesive Yes No
Environmental Yes No
Any Allergy to Medications Yes No
*** If so please list:
Other Allergies (please list):
Has ANY biological family member had a
problem with anesthesia?
Yes-Relationship __________________________________
No
Does your child have any IMPORTANT MEDICAL CONDITIONS: Please Answer Each Question
(Circle Answer)
Does your child have or had: If yes, list type of condition Name of treating physician
Any blood conditions Yes No
Asthma Yes No Last episode:
Heart Problems/Murmur Yes No
Diabetes Yes No Insulin Dependent? Yes No
Neurological Yes No
Has your child had any OPERATIONS/ HOSPITALIZATIONS? (Including Overnight Observations) Procedure / Reason for Hospitalizations Date Hospital/ Doctor
_______________________________ _________________ ________________ SIGNATURE DATE TIME
__________________ __________ Signature Review Date
______________________________ ______________
Signature Review Date For updating use only
Patient Name: ____________________________________________ Date of Birth: _____________________________
*Patient Review of Systems* Please check the box to the right of the condition if your child presently has or has been previously diagnosed with any of the
following. If condition is resolved, please put an “R” in the box. Constitutional:
Fatigue Night Sweats Weight Loss
Failure to Thrive Other _____________________________ Integumentary/Skin:
Rash Lesion Abscess
Eczema MRSA Other ____________
Neurological:
Cerebral Palsy ADD ADHD
Convulsions Epilepsy Asperger’s Syndrome
Seizures Fainting Spells Autism
Paralysis Stroke Dizziness
VP Shunt Headaches Other____________
Respiratory:
Chronic Cough Lung Disease Empyema
Pneumonia Tuberculosis Tracheostomy
RSV Asthma (please also list on other side)
Pulmonary Embolism Bronchopulmonary Dysplasia
TE Fistula Other _____________________________
Cardiac:
Murmur Enlarged Heart Rheumatic Fever
Irregular Heart Beat Congenital Heart Disease
Mitral Valve Prolapse Other____________________________
Intestinal & GU:
Colitis/IBS Constipation Necrotizing Entercolitis
Gallstones Kidney Stone Kidney Infection
Bed Wetting Ulcer GE Reflux Disease
Gallbladder Disease Diarrhea Imperforate Anus
Difficulty Swallowing Ovarian Cysts Frequent Urination
Vomiting/Nausea Hydronephrosis Biliary Dyskinesia
Retractile Testes Crohn’s Disease Undescended Teste
Breast Mass/cyst Other_____________________________
Hematology & Lymphatic:
Hepatitis Bruising Lyme disease
Nosebleeds Anemia Sickle Cell
Circulatory Disease Epstein-Barr Blood Clotting Disease
Mononucleosis Other_____________________________
Oncology:
Cancer Leukemia Radiation Therapy
Wilms’ Tumor Chemotherapy Other ____________
Allergy & Immune:
Seasonal Allergies Mitochondrial Deficiency
HIV/AIDS Other______________________________
Genetics:
Down syndrome Cystic Fibrosis Marfan’s syndrome
Other: __________________________________________________
Endocrine:
Diabetes Hyper or Hypo Thyroidism
Growth Deficiency Other _____________________________
Psychological:
Depression Bipolar Schizophrenia
Anxiety OCD Other_____________
*SOCIAL HISTORY*
Number of siblings? _____________________
Is your child in daycare? Yes No
Does your child attend school? Yes, Grade ____ No
Is your child home schooled? Yes No
Is your child in college? Yes No
Who is the child’s legal guardian? _______________________
With whom does the child reside? _________________________
Who is the primary caregiver for your child, and what is the
relationship to the child? ________________________________
Please list any sports or extra-curricular activities your child
participates in. If none, please check
____________________________________________________
____________________________________________________
*BIOLOGICAL FAMILY HISTORY* If any biological family members have any medical conditions,
please indicate what conditions.
Adopted? Yes No (please circle) Country____________
If adopted, please complete below.
Were you informed of any pertinent family history? Yes No
Would you rather we not disclose in front of child? Yes No
(Check box if deceased & provide condition)
Mother____________________________________________
Father____________________________________________
Siblings___________________________________________
Maternal Grandmother________________________________
Maternal Grandfather_________________________________
Paternal Grandmother________________________________
Paternal Grandfather_________________________________
Other_____________________________________________
Do you have pets at home or does your child come in contact with
pets on a consistent basis? Yes No (If so, list type)
__________________________________________________________
If there is any other information that you would like us to know
about your child? Please inform us in the space below.
___________________________________________________________
____________________________________________
______________________________ ______________
Signature Review Date
______________________________ ______________
Signature Review Date For updating use only
SIGNATURE DATE TIME
For Internal Use Only: Scan document into HIPPA form folder in CB Revised 5/14
Acknowledgment of Receipt of Notice and Approval of Privacy Practices
Patient Name: ________________________________ Patient’s Date of Birth: _______________________
I, ______________________________________________, hereby acknowledge that I have
received the corresponding HIPAA Notice of Privacy Practices. I also further acknowledge and
approve the uses and disclosures of my PHI as described in the HIPAA Notice of Privacy Practices.
Date: ______________________.20______ ____________________________________
Signature of Patient or Representative
Patient Contact Authorization
I, ______________________________________________, (patient or legal representative name)
authorize and give permission to Meridian Pediatric Surgical Associates, or any practice staff
members, to leave messages regarding ___________________________ (fill in patient’s name)
medical information on the following telephone(s):
Home: ( ) ____________-_______________
Cell: ( ) ____________-_______________
I authorize and give permission to Meridian Pediatric Surgical Associates, or any practice staff members,
to speak with the following people regarding ______________________________ (fill in patient’s name)
medical status and/or treatment
Name: ______________________________________ Relationship: _______________________
Name: ______________________________________ Relationship: _______________________
Name: ______________________________________ Relationship: _______________________
Patient Signature: _______________________________ Date: ___________________________
HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES, PC
Victoriya Staab, M.D.
Christine M. Williams, PA- C
4 Industrial Way West Suite 100, Eatontown, NJ 07724
Phone: 732-935-0407 Fax: 732-935-0757
www.meridianpediatricsurgery.com
This Joint Notice of Privacy Practices (“Notice”) explains how Hackensack Meridian Health (collectively “HMH”) uses information about you and when HMH can share
that information with others. It also informs you about your rights as a valued customer.
This Notice is being provided to you on behalf of HMH, which includes our hospitals (see below listing), Meridian Home Care Services, Inc., Meridian Nursing and
Rehabilitation, Inc., and the independent members and independent health professional affiliates of the medical staffs of HMH (collectively with “HMH” referred to
herein as “us”, “we” or “our”) with respect to services provided by HMH. Please note that the independent members and independent health professional affiliates of the
medical staffs are neither employees nor agents of HMH, but are joined under this Notice for the convenience of explaining to you your rights relating to the privacy of
your protected health information (“PHI”).
HMH respects the privacy and confidentiality of your PHI. The federal law, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), sets rules about
who can look at and receive your health information. This law, and applicable state law, gives you rights over your health information, including the right to get a copy of
your health information, make sure it is correct, and know who has seen it.
Please review this Notice carefully.
ORGANIZED HEALTH CARE ARRANGEMENT (“OHCA”)
An Organized Health Care Arrangement (“OHCA”) is an arrangement or relationship that
allows two or more HIPAA covered entities to use and disclose PHI. A HIPAA covered entity
is any organization or corporation that directly handles PHI or Personal Health Records (PHR).
The most common examples of covered entities include hospitals, doctors’ offices and health
insurance providers. The entities participating in the HMH OHCA are covered entities under
HIPAA and will share PHI with each other, as necessary to carry out treatment, payment or
health care operations relating to the OHCA. The entities participating in the HMH OHCA agree to abide by the terms of this Notice with
respect to PHI created or received by the entity as part of its participation in the OHCA. The
entities, which comprise the HMH OCHA, are in numerous locations throughout the greater
New Jersey area. This Notice applies to all of these sites. For a complete list of locations,
please refer to last page of this Notice.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION Each time you visit or interact with a hospital, physician, or other health care provider, a record
of your visit is made. Typically, this record contains your symptoms, examination and test
results, diagnoses, treatment, and a plan for future care or treatment. This information, often
referred to as your health or 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 services billed were actually provided
A tool in educating health professionals
A source of data for medical research
A source of information for public health officials charged with improving the health of the nation
A source of data for facility planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:
Ensure its accuracy
Better understand who, what, when, where, and why others may access your
health information
Make more informed decisions when authorizing disclosure to others
YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of the health care practitioner or facility
that compiled it, the information belongs to you. You have the right to:
Request a restriction on certain uses and disclosures of your information, however, HMH is not required to agree to such a request if the facts do not warrant it.
Obtain a paper copy of the Notice of Privacy Practices upon request
Inspect and obtain a paper or electronic copy of your health record usually within
30 days of your request. We may charge a reasonable, cost-based fee.
Request an amendment (correction) to your health record if you believe
information is incorrect or incomplete
Obtain a list (an accounting of disclosures) of the times we have shared your health information for six years prior to the date you asked, who we shared it with,
and why. Exceptions: treatment, payment and health care operations.
Request communications of your health information by alternative means or at
alternative locations. For example, you may request that we send correspondence to a post office box rather than your home address.
Revoke your authorization to use or disclose health information except to the extent that action
has already been taken. If you pay for a service out-of-pocket in full, you can request that
information not be shared for the purpose of payment or our operations with your health
insurer.
You will be asked to sign an acknowledgment that you have received this Notice. We are
required by law to make a good faith effort to provide you with the Notice and to obtain
your acknowledgment. Your refusal to accept the Notice or to sign the acknowledgment will in no way affect your care or treatment in our facility.
HACKENSACK MERIDIAN HEALTH’S RESPONSIBILITIES
Maintain the privacy and security of your health information
Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this Notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location
Notify you if a breach occurs that may have compromised the privacy or security of your information
We reserve the right to change our practices and to make the new provisions effective for
all PHI we maintain. Should our information practices change, revisions will be available
at www.HackensackMeridianHealth.orq and you may request a revised copy from the
Office of Privacy, the Office of Patient Experience or any patient registration areas. The
HMH Chief Compliance Officer is responsible for maintaining the Notice of Privacy
Practices and for archiving previous versions of the Notice.
We will not use or disclose your health information without your authorization, except as described in this Notice and for treatment, payment, or health care operations.
Note: HIV-related information, genetic information, alcohol and/or substance abuse
records, mental health records or other specially protected health information may have
additional confidentiality protections under applicable State and Federal law. We will
obtain your specific authorization before using or disclosing these types of information
where we are required to do so by such applicable State and Federal laws. However, we
may be permitted to use and disclose such information to our physicians to provide you with treatment.
EXAMPLES OF PERMITTED DISCLOSURES OF PROTECTED HEALTH
INFORMATION FOR TREATMENT, PAYMENT & HEALTH CARE
OPERATIONS
We will use your health care information for Treatment.
For example: Information obtained by a nurse, physician, or other member of your health
care team will be recorded in your record and used to determine the course of treatment. Members of your health care team will record the actions they took, their observations, and
their assessments. In that way, your health care team will know how you are responding to
treatment. We will also provide your physician or a subsequent health care provider with
copies of various reports that should assist him or her in treating you once you are
discharged from this facility.
We will use your health care information for Payment.
For example: A bill will be sent to you and/or a third-party payer (insurance company).
The information on the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may provide copies of the applicable
portions of your medical record to your insurance company in order to validate your claim.
We will use your health care information for regular Health Care Operations.
For example: We may use and disclose PHI for activities that HMH engages in to operate
its business, such as quality assurance, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits,
business planning, development and the management of health outcomes, including the
identification of opportunities to improve the health of individuals or groups of individuals.
In addition, we may remove information that identifies you from your patient information
so that others can use the de-identified information to study health care and health care
delivery and implement quality improvement initiatives without learning who you are.
OTHER USES & DISCLOSURES OF PROTECTED HEALTH INFORMATION
HEALTH INFORMATION EXCHANGE HMH, along with other health care providers in New Jersey participate in Jersey Health
Connect, a health information exchange (“HIE”) which allows patient information to be shared electronically through a secured network that is accessible to the providers treating you. We
may disclose your PHI to the HIE unless you opt out of participating. To opt out, please contact
Jersey Health Connect at (855) 624-6542.
PERSONAL HEALTH RECORD
A personal health record (PHR) is an electronic application used by patients to maintain and
manage their health information in a private, secure, and confidential environment. PHRs:
Are managed by patients
Can include information from a variety of sources, including health care providers and patients themselves
Can help patients securely and confidentially store and monitor health information, such as diet plans or data from home monitoring systems, as well as patient contact
information, diagnosis lists, medication lists, allergy lists, immunization histories, and
much more
Are separate from, and do not replace, the legal record of any health care provider
Are distinct from portals that simply allow patients to view provider information or
communicate with providers
Note: In addition to the HIE, HMH uses MyChart which allows you to exchange secure
electronic messages with your physician or allows you to request medical appointments. Kindly
check with your HMH provider to see which PHR applies to you.
BUSINESS ASSOCIATES We may disclose your health information to contractors, agents and other associates who need
this information to assist us in carrying our business operations. Our contracts with them
require that they protect the privacy of your health information in the same manner as we do.
FACILITY DIRECTORY Unless you notify us that you object, HMH will release your name and location to the general
visiting public while you are a patient in a HMH facility. In addition, your religious affiliation
will be made available to the visiting clergy.
NOTIFICATION We may use or disclose information about your location and general condition to notify or
assist in notifying a family member, personal representative, or another person responsible for your care.
COMMUNICATION WITH FAMILY As long as you do not object, your health care provider is permitted to share or discuss your
health information with your family, friends, or others to the extent that they are involved in
your care or payment for your care. Your provider may ask your permission or may use his or
her professional judgment to determine the extent of that involvement. In all cases, your health
care provider may discuss only the information that the person involved needs to know about your care or payment for your care.
RESEARCH We may disclose information to researchers when their research has been approved by HMH.
INSTITUTIONAL REVIEW BOARD (“IRB”) The IRB reviews the research proposals and establishes protocols to ensure the privacy of your
health information.
FUNERAL DIRECTORS OR CORONERS We may disclose health information to funeral directors or coroners consistent with applicable
law to carry out their duties.
ORGAN AND TISSUE DONATION If you are an organ donor, we may release PHI to organizations that handle organ procurement
or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
TELEPHONE CONTACT/APPOINTMENT REMINDERS 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
call you after you have been a patient to ask about your clinical condition or to assess the
quality of care that you received.
FUNDRAISING The Hospitals of HMH affiliated Foundations may contact you as part of a fundraising effort.
The information used for this purpose will not disclose any health condition, but may include
your name, address, phone number, email address, etc. When contacted, you may ask that we
stop any future fundraising requests if you so desire.
IMAGES
The hospitals of HMH may record digital or film images of you, in whole or in part, for
identification, diagnosis or treatment purposes and for internal purposes such as performance improvement or education. Such images may be used for documenting or planning care,
teaching, or research. The medical center will obtain your authorization for any other use your
identifiable image that is unrelated to treatment, payment or heath care operations.
FOOD AND DRUG ADMINISTRATION (“FDA”)
We may disclose to the FDA health information relative to adverse events with respect to
food, supplements, product and product defects, or post marketing surveillance information
to enable product recalls, repairs, or replacement.
WORKERS COMPENSATION
We may disclose health information to the extent authorized and to the extent necessary to
comply with laws relating to worker’s compensation or other similar programs established by law.
OCCUPATIONAL HEALTH
We may disclose your PHI to your employer in accordance with applicable law, if we are
retained to conduct an evaluation relating to medical surveillance of your workplace or to
evaluate whether you have a work-related illness or injury. You will be notified of these
disclosures by your employer or HMH as required by applicable law.
PUBLIC HEALTH & SAFETY
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
If you are an inmate of a correctional institution or under the custody of a law enforcement
official, we may release PHI about you to the correctional institution or law enforcement
official. This release would be necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of others; or (3) for the
safety and security of the correctional institution.
LAW ENFORCEMENT
We may release PHI 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 under certain limited circumstances;
About a death we believe may be the result of criminal conduct;
About criminal conduct on our premises; and
To report a crime, the location of the crime or the victims, or the identity,
description or location of the person who committed the crime.
Federal law makes provision for your PHI to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business
associate believes in good faith that we have engaged in unlawful conduct or have
otherwise violated professional or clinical standards and are potentially endangering one or
more patients, workers or the public
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you believe that your privacy rights have been violated, you should immediately contact
the Office of Patient Experience with the entity from which you received services or the
HMH Privacy Office. You may also file a complaint with the Secretary of Health and Human Services at (877) 696-6775 or by visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. There will be no retaliation for filing a
complaint.
HACKENSACK MERIDIAN HEALTH HOSPITALS
• HackensackUMC
• Jersey Shore University Medical Center
• Joseph M. Sanzari Children’s Hospital
• K. Hovnanian Children’s Hospital
• Ocean Medical Center
• Riverview Medical Center
• HackensackUMC Mountainside
• HackensackUMC Palisades
• Raritan Bay Medical Center in Perth Amboy
• Southern Ocean Medical Center
• Bayshore Community Hospital
• Raritan Bay Medical Center in Old Bridge
• HackensackUMC at Pascack Valley
Effective July 1, 2016