Patient Rights/Privacy/Public Notice

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare 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
  • Tool in educating health professionals
  • Source of data for medical research
  • Source of information for public health officials charged with improving the health of the nation
  • Source of data for facility planning and marketing
  • 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

Good Shepherd’s Responsibilities

Good Shepherd is required by law to:

  1. maintain the privacy of your health information;
  2. provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you;
  3. provide you with information about your individual rights.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Protected health information means any information about you that identifies you or for which there is a reasonable basis to believe that the information can be used to identify you. Should our privacy practices change, we will provide you with a current copy of this notice upon your next visit.


We may use or disclose your health information as necessary for purposes of treatment, payment and healthcare operations. We have provided examples for the types of permitted uses and disclosures for treatment, payment and healthcare operations. Not every use in the following categories will be listed. However, all of the ways in which we are permitted to use and disclose your health information will fall within one of the categories listed in this notice.

Treatment. We may use your health information to provide, coordinate or manage your healthcare and related services provided by us as well as other health care providers. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from this facility. We may consult with other healthcare providers concerning your care and, as part of the consultation, share your medical information with them.

Payment. We may use and disclose your health information so that we can be paid for the services we provide to you. This can include billing you, your insurance company or a third party payer. For example, we may need to give your insurance company information about the health care services we provide to you so your insurance company will pay us for those services or reimburse you for the amounts that you have paid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health Care Operations. We may use and disclose your health information for our own health care operations. Members of the medical staff, the risk or quality improvement director, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide to you. We may disclose your health information to train our staff, volunteers and students working at Good Shepherd.


In addition to the use and disclosure of your health information for treatment, payment and health care operations, we may also use and disclose your health information for other purposes:

Business Associates. There are some services provided in our organization through contracts with "business associates," such as accounting, legal representation, claims processing, consulting and claims auditing. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. If we disclose health information to a business associate we will do so subject to a contract that provides that the information will be kept confidential.

Directory. Unless you notify us that you object, we will use your name, location in the facility, general condition and religious affiliation for our internal directory purposes. Our directory does not include specific medical information about you. We may release information in our internal directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.

Appointments. We may use your health information for appointment reminders. For example, we may look at your medical record to determine the date and time of your next appointment with us, and then send you a reminder letter or call you to help you remember the appointment.

Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose your health information to recommend or inform you about possible treatment options or alternatives or health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care. Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person identified by you, health information relevant to that person’s involvement in your care or payment related to your care. You have the right to object to such disclosure, unless you are unable to function or there is an emergency. We may also disclose your health information to notify or assist in the notification of a family member or other person responsible for your care of your location, general condition or death.

Disaster Relief. We may release your health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status.

Research. We may disclose information to researchers when their research has been approved by our institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral Directors, Coroners, and Medical Examiners. We may disclose health information to funeral directors, coroners, and medical examiners consistent with applicable law to carry out their duties related to your death, such as identifying the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.

Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Fundraising. Unless you notify us in writing that you object, we may use information in your medical record, such as your name, address, phone number, and treatment dates to contact you as part of a fundraising effort. For example, in order to provide more charity care or otherwise improve the health of your community, we may want to raise additional money and therefore may contact you for a donation. Good Shepherd will not share your health information with entities not affiliated with Good Shepherd for such other entity’s fundraising purposes.

Serious Threat to Health or Safety. As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.

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 Activities. 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. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety. 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.

Health Oversight Activities. We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs; for example: The Joint Commission on Accreditation of Healthcare Organizations (Joint Commission); The Commission on the Accreditation of Rehabilitation Facilities (CARF) and the Pennsylvania Department of Health.

Military, National Security, or Incarceration/Law Enforcement Custody. Should you be an inmate of a correctional institution, or involved with the military, national security or intelligence activities, we may disclose health information necessary for your health and the health and safety of other individuals and to allow the proper authorities to carry out their duties under the law.

Law Enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.

As Required by Law. We may use or disclose your medical information when we are required to do so by law.

Victims of Abuse, Neglect or Domestic Violence. We may disclose your health information to a government authority authorized by law to receive reports of abuse, neglect or domestic violence, if we believe that you are a victim of abuse, neglect, or domestic violence. We will only make this disclosure if we are required or authorized to do so by law or if you agree to such disclosure.

Judicial and Administrative Proceedings. We may disclose your health information in response to a subpoena, court order or other legal process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed. In the event that Pennsylvania laws afford greater protection with respect to the disclosure of your health information, we will follow Pennsylvania law.


Other types of uses and disclosures of medical information not identified in this notice will be made only with your written authorization. That authorization may be revoked, in writing, at any time. However, should you revoke such an authorization, you should understand that we are unable to retract any disclosures we have already made with your permission and that we are required to retain our records as proof of the care that we provided you.


Right to request restrictions.
You have the right to request that we restrict the uses or disclosures of your medical information to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or (b) to public or private entities for disaster relief efforts. For example, you could ask that we not disclose medical information about you to your brother or sister. We are not required to agree to any requested restriction, but will tell you in advance if we cannot comply. However, if we do agree, we will follow that restriction unless the information is needed to provide you with emergency treatment.

You must submit your limitation or restriction request in writing to our privacy specialist at the address indicated at the end of this notice or to the person or persons providing you with care at Good Shepherd. In your request you must tell us: (1) what information you would like to limit or restrict; (2) whether you wish to limit the use or disclosure, or both; and (3) to whom you would like the limits to apply, for example, disclosures to your spouse.

We may terminate your restriction if: (a) you agree or request the termination in writing; (b) you orally agree to the termination; or (c) if we inform you that we are terminating our agreement to your restriction, except that such termination will only be effective for your medical information that is created or received after you receive our notice of termination.

Right to receive confidential communications.
We will accommodate reasonable requests to receive communications about your medical information from us by alternative means or to alternative locations. For example, you may ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communications. If you want to request confidential communications, you must make your request in writing to our privacy specialist at the address indicated at the end of this notice or to the person or persons providing you with care at Good Shepherd.

Right to inspect and copy protected health information.
With a few very limited exceptions, you have the right to inspect and obtain a copy of your medical information. To inspect or copy your medical information, you must submit your request in writing to our Corporate Director of Health Information Management at 543 St. John Street, Allentown, PA18103. Your request should specifically state what medical information you want to inspect or copy. We will ordinarily act on your request within 30 days of our receipt of your request.

We may charge a fee for the costs of copying, mailing or other supplies associated with your request and will tell you the fee amount in advance. We may deny your request to inspect and copy in limited circumstances. If you are denied access to your medical information, you may submit a written request that such denial be reviewed to our privacy specialist at the address indicated at the beginning of this notice. In certain circumstances you will not be granted a review of a denial. Your denial of access will be reviewed by a licensed health care professional designated by us who did not participate in the original decision to deny access. We will ordinarily act on your request for review within 30 days.

Right to amend protected health information.
You have the right to request an amendment to your medical information. You have the right to request an amendment for as long as the information is kept by or for us. Your request must be submitted in writing to our Corporate Director of Health Information Management and must specifically state your reason or reasons for the amendment. We will ordinarily act on your amendment request within 60 days after our receipt of your request.

We may deny your request to amend medical information if we determine that the information: (1) was not created by us; (2) is not part of the medical information maintained by us; (3) would not be available for you to inspect or copy; or (4) is accurate and complete.

If we grant the request, we will inform you of such acceptance in writing. We will make the appropriate amendment to your medical information and we will request that you identify and agree that we may notify all relevant persons with whom the amendment should be shared: (a) individuals that you have identified as having medical information about you and (b) business associates that we know have your medical information that is the subject of the amendment.

Right to receive an accounting.
You have the right to request an "accounting of disclosures" for disclosures of your medical information that are made after April 14, 2003. The list of disclosures does not include disclosures: (a) for treatment, payment and healthcare operations; (b) made with your authorization or consent; (c) to your family member, close relative, friend or any other person identified by you; or (d) for national security or intelligence purposes. Additionally, under certain circumstances, government officials can request that we withhold disclosures from the accounting.

To request an accounting of disclosures, you must submit your request in writing to our Corporate Director of Health Information Management at 850 South 5th St., Allentown, PA18103. Your request must state the time period for which you would like an accounting which may not be longer than 6 years.

Your first accounting request within any 12-month period will be provided to you free of charge. For additional accounting lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

We will ordinarily act on your accounting request within 60 days of your request. We are permitted to extend our response time for a period of up to 30 days if we notify you of the extension. We may temporarily suspend your right to receive an accounting of disclosures of your medical information, if required to do so by law.

You may complain in writing to the privacy specialist at the address indicated at the end of this notice and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint in care of:

Office for Civil Rights, U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington, D.C. 20201.

You will not be retaliated against for filing a complaint.

Contact Information - Questions, Comments or Requests
If you have any questions about this notice please contact our Director of Quality, Performance, and Compliance at 850 South 5th Street, Allentown, Pennsylvania 18103-3295; (610) 778-9266.


The purpose of the survey is to evaluate the organization’s compliance with established Joint Commission standards. The survey results will be used to determine the terms and conditions under which accreditation should be awarded to the organization.

Joint Commission standards deal with organizational quality of care issues and the environment in which care is provided. Anyone believing that he or she has pertinent information about such matters may request a Public Information Interview with the Joint Commission’s field representatives at the time of survey. Information presented at the interview will be carefully evaluated for relevance to the accreditation process. The request should indicate the nature of the information to be provided at the interview.

Please address written requests to:

Division of Accreditation Operations
Office of Quality Monitoring
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

Or Fax your request to 630-792-5636
Or E-mail your request to: complaint@Joint
Or you may call the Joint Commission directly at 1-800-994-6610.

The Joint Commission will acknowledge such a request in writing, or by telephone, and will notify Good Shepherd of the request for any interview. Good Shepherd will then notify the interviewee of the date, time and place of the meeting.


A survey team from CARF will be visiting our premises on September 17-18, 2009. CARF is an international, not-for-profit organization that accredits human services providers. Founded in 1966 as the Commission on Accreditation for Rehabilitation Facilities, the accrediting body is now known as CARF.

We invited the CARF surveyors to evaluate how well our services meet international standards for quality. The survey team will be looking at many things about us and our services. The survey will tell us what we are doing well and ways we might improve. As a result of this survey, our services may earn or continue CARF accreditation.

As part of the survey, the surveyors will interview people who use our services, their families, our staff, and others. Some questions the survey team members might ask people are:

  • Are our services provided in a clean and safe setting?
  • Do you receive the services you need and want?
  • Are you treated with respect?
  • Do you take part in planning your services?
  • Are you told what you need to know about your services?
  • Are your questions answered in a way you understand?
  • Do you know where to go with questions or concerns?

If you would like to talk with one of the CARF survey team members or want to learn more about CARF, please let one of our staff members know.

You may also contact CARF directly.

  • Internet:
  • E-mail:
  • Mail: CARF, 4891 E. Grant Road, Tucson, AZ 85712
  • Toll-free telephone: (866) 510-2273
  • Fax: (520) 318-1129