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Notice of Privacy Practices

Effective Date: September 1, 2017


Each time you visit a Baystate Health, Inc. facility, affiliated practice, or other affiliated health care provider (“Baystate”) for patient services, we create a record of your care. This record, which is the property of Baystate, typically contains information about your symptoms, examinations and tests, diagnoses and treatments, plans for future care, and billing information. We understand that your medical information is personal, and we are dedicated to maintaining the privacy of this information.

We are required by law to:

  • Maintain the privacy and security of your protected health information (“PHI”).
  • Provide you with notice of our legal duties and privacy practices concerning your PHI.
  • Follow the duties and privacy practices described in this notice and give you a copy of it.
  • Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

Protected health information (“PHI”) includes information that relates to your past, present or future health care or the payment for that care, and that can reasonably be used to identify you. Protected health information does not include information regarding a person who has been deceased for more than 50 years.

Baystate reserves the right to change the terms of its notice of privacy practices and to make provisions of the new notice effective for all protected health information maintained by Baystate. We will post a copy of any revised notice of privacy practices in our facilities and at our website:; and, upon your request, we will provide you with a copy of any such revised notice of privacy practices.


You have received this notice because you are seeking patient services from Baystate which may include the following affiliated entities and health care providers:

  • Baystate Medical Center, Inc.
  • Baystate Franklin Medical Center
  • Baystate Noble Hospital Corporation and its Subsidiaries
  • Baystate Medical Practices, Inc.
  • Baystate Health, Inc.
  • Baystate Wing Hospital Corporation
  • Noble Visiting Nurse Services, Inc.
  • Visiting Nurse Association and Hospice of Western New England, Inc.

Each affiliated hospital listed above also participates in an organized health care arrangement (OHCA) with the Medical Staff and Associate Professional Staff of that hospital. The various affiliated Baystate entities and health care providers will share your medical information among themselves, as required or permitted by law, including as necessary to carry out treatment, payment and health care operations and as described below. Also, we participate in secure health information exchanges (“HIEs”), such as those operated by Pioneer Valley Information Exchange and the Massachusetts statewide HIE (“Mass HIway”). HIEs help coordinate patient care efficiently by allowing health care providers  involved in your care to share health information with each other in a secure and timely manner. Your health information will be accessed, used and disclosed via the HIEs in which Baystate participates for purposes of treatment, payment and health care operations.


The following categories describe different ways that we use and disclose medical information without your written authorization. Please note that each particular use or disclosure is not listed. However, the different ways in which we are permitted to use and disclose your medical information without your written authorization generally fall within one of the categories listed.

Treatment. We may use and disclose medical information about you to provide you with medical treatment or services. We may disclose this information to doctors, nurses, technicians, residents, students, or other health care personnel involved in your care at Baystate. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments in the Baystate facilities may also share medical information about you to coordinate the different services you need, such as lab work and X-rays. For example, lab and X-ray results may be requested and shared with an emergency department physician who is treating you. Baystate may also share medical information with other providers who may be treating you, such as the doctor who referred you to Baystate or to whom a Baystate provider refers you or who is otherwise involved in your care.

Payment. We may use and disclose your medical information to bill and collect payment for services delivered by Baystate. For example, if you have health insurance, we will need to give to the health plan or government agency (for example, Medicare or Medicaid) information about the services you received so that your plan will pay us. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations. We may use and disclose medical information to run our organization, improve your care, and contact you when necessary. We may share information with doctors, nurses, technicians, students, and other health care personnel for review and learning purposes. For example, we may use medical information about you to review our treatment and services and to evaluate the performance of our staff in caring for you. We may combine medical information about you with information from other hospitals to compare and identify areas where we can make improvements. We may share medical information for Baystate Health sciences and other teaching programs.

Fundraising Activities. We are a not-for-profit health system that depends on charitable support to serve our community. We may share your information with our affiliate Baystate Health Foundation in order for the Foundation to inform you of opportunities to support Baystate and its programs and services. You have the right to opt out of receiving such communications.

Hospital Directory. We may include certain limited information about you in a hospital directory while you are a patient at Baystate. This information may include your name, location, your general condition (e.g., fair, good, etc.) and your religious affiliation. Unless you object, the directory information may be released to people who ask for you by name or to members of the clergy, such as a priest or rabbi.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose medical information about you to a friend or family member who is involved in your medical care or to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research. We can use or share your information for health research. We have to meet many conditions in the law before we can use or share your information for the purpose of research. For more information, click here.

As Required or Permitted By Law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We may also use and disclose medical information about you when permitted by law to do so. For example, we may disclose health information to:

  • The Food and Drug Administration
  • Public Health authorities charged with preventing or controlling disease, injury or disability
  • Organ and Tissue Donation Organizations
  • Health Oversight Agencies
  • Funeral Directors, Coroners and Medical Examiners
  • National Security and Intelligence Agencies

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you to help prevent a serious threat to the health or safety of you, the public or another person.

For Public Health Activities. We may use and disclose your medical information for public health activities, such as:

  • To prevent or control disease, injury or disability.
  • To report births and deaths.
  • To report suspected abuse, neglect or domestic violence.
  • To report reactions to medications or problems with products.
  • To notify you of recalls of products or medical devices that you may be using.
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

We will only make this disclosure if you agree or when we are required or authorized by law to do so.

Respond to Lawsuits and Legal Actions. We may use and disclose medical information as required by a court or administrative order, or in some instances pursuant to a subpoena, discovery request or other legal process. We may also share your information with law enforcement to report a crime, the location of the crime or victims, or the identity, description or location of the person who may have committed a crime.


We have described in the preceding paragraphs those uses and disclosures of your medical information that we may make either as permitted or required by law or otherwise without your written authorization. For other uses and disclosures of your medical information, we must obtain your written authorization. We must obtain your written authorization for most uses and disclosures of psychotherapy notes, for uses and disclosures of medical information for marketing purposes, and for disclosures of medical information that constitute a sale of the information. A written authorization request will, among other things, specify the purpose of the requested disclosure, the persons or class of persons to whom the information may be given, and an expiration date for the authorization. If you do provide a written authorization, you may change it at any time. Let us know in writing if you change your mind.


You have the following rights regarding medical information we maintain about you.

Get an electronic or paper copy of your medical record. You have the right to see or get an electronic or paper copy of your medical and billing records. If you would like to see or get a copy of your records, you must submit the request in writing to the Health Information Management Department of the Baystate facility or the physician office(s) where you received treatment. You may also request that this information be sent to another individual. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record. If you feel the medical information Baystate has about you is incorrect or incomplete, you may ask us to correct the information. You must make your request in writing and submit it to the Health Information Management Department of the Baystate facility or the physician office where you received treatment. You must include the reason you are making the request. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of disclosures we made of medical information about you, except for disclosures to carry out treatment, payment or health care operations, and certain other disclosures (such as any you asked us to make). You must submit your request for an accounting of disclosures in writing to the Health Information Management Department of the Baystate facility or physician office where you received treatment.

Request Restrictions. You have the right to request a restriction on the medical information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request, and we may say “no”. If you pay for a health care item or service out of pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. To request restrictions, you must make your request in writing to the Health Information Management Department of the Baystate facility or physician office where you received treatment.

Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or in a certain location (for example, you can request we contact you only at work or by mail). To request confidential communications, you must make your request in writing to the Health Information Management Department of the Baystate facility or the physician office where you received treatment. We will not ask you the reason for your request, and we will say yes to all reasonable requests if we are able to do so. In your request, you must specify how or where you wish to be contacted (such as an alternative address or telephone number).
Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Complaints. If you believe your privacy rights have been violated, you may contact the Baystate Health Privacy Officer at 877-874-RIGHT (7444) or 413-794-7955, or on-line at

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, DC 20201, calling 1-877-696-6775, or learn from from U.S. Department of Health & Human Services.

We will not retaliate against you for filing a complaint.

Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time, which is also posted on our website.To obtain a paper copy, please contact the Baystate Health Privacy Officer at 413-794-7955.

Unless we provide you with a different Notice, this Notice will apply to all provider entities that Baystate Health may acquire or affiliate with in the future.