Notice of Privacy Practices

Effective Date: March 1, 2016



Medical information is personal and private.  Medical information referred to as Protected Health Information (PHI) is individually identifiable information about an individual child or adult and includes all paper and electronic records.  This notice describes the ways we may use and disclose your Protected Health Information, or the Protected Health Information of your child if you are a parent or legal guardian. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.  This Notice applies to all staff at Franciscan Children’s, its physicians, nurses, and other personnel.

What are my child’s privacy rights?

Patients younger than the age of 18 are usually considered minors.  The parents or legal guardians of minor patients may generally make decisions about their children’s medical care and may exercise the privacy rights described in this Notice. Minor patients are allowed by law to make decisions about their own medical care in some situations, and in those situations they usually also control the release of their medical information even to their parents/legal guardians.

How may we share your information without your permission/authorization?

Generally, we may use and share your PHI to provide patient care, receive payment for services, support health care operations, contact you and perform research. The most common reasons are listed below along with some examples and exceptions:

  • Treatment. We may use your medical information to give you medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other health care personnel who care for you at the hospital or outside the hospital. We may also disclose medical information about you to people involved in maintaining your health or well-being during your hospital stay and after discharge.
  • Payment. We may use and disclose your medical information so that the treatment and services you receive may be billed and payment may be collected from you, an insurance company, or a third party. We may tell your health plan about a treatment you are going to receive in order to get prior approval or to find out if your plan will cover the treatment. We may also give information to someone who helps pay for your care.
  • Health Care Operations. We may use and disclose your medical information for health care operations. Health care operations are activities that are necessary to run the hospital or physician office and to make sure that all of our patients receive quality care. We may combine medical information about many patients so we can make decisions about what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes.

How else may we use or share your information without your permission?

  • Communication with You. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. We may also use it for registration/insurance updates, billing or payment matters, pre-procedure assessment or test results.
  • Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or health related benefits that may interest you.
  • Workers’ Compensation. We may release your medical information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
  • Public Health Activities. When requested, we may disclose your medical information for public health activities.
  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report abuse and/or neglect of a child, elder or disabled person;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using; or
  • 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.
  • Research. We may disclose information to researchers when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. This also may include preparing for research or telling you about research studies that might interest you.
  • As Required By Law. We will disclose your medical information when required to do so by federal, state or local law.
  • To Avert a Serious Threat to Health or Safety. We may use and disclose your medical information when it is 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 be only to someone able to help prevent the threatened harm.
  • Organ and Tissue Donation. If you are a potential organ donor, we may release medical information to organ procurement organizations or eye or tissue banks.
  • Health Oversight Activities. We may, when requested, give your medical information to a health oversight agency for activities authorized by law. These activities include audits, certifications, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court order. Under certain circumstances, we may also disclose your medical information in response to a subpoena or other lawful process. We will do so only if efforts have been made to tell you about the request or to get an order protecting the information requested or if you or a court have given written authorization.
  • Law Enforcement. If permitted by law, we may release your medical 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 our facility; and
  • 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.
  • Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner.
  • National Security and Intelligence Activities. If permitted by law, we may release your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities, as authorized by law.

How we may use or share your information if you do not object?

  • Disclosures to Family, Friends or Others. We may share relevant health information about you with a family member or other person close to you if they are involved in your care or payment for your care. At your request, or if we believe it is in your best interest, we may share your PHI with others who are not your parent or legal guardian but who are active participants in your care. We will only share information that we believe others need to know in your best interest and if you have not specifically objected to its use or disclosure.
  • Hospital Directories. We may include certain limited information about you in the hospital directory while you are an inpatient. This information may include your name, location in the hospital, your general condition (good, fair, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be given to members of your family, friends, and to others who ask for you by name. Your name may be given to a member of the clergy, even if they do not ask for you by name. If you do not want to be listed in the hospital directory, please tell your nurse. You may also ask to limit the information that is given out about you. If you are in an emergency situation and are not able to make your wishes known, we will put this information in the directory if we think it is in your best interest.
  • Fundraising Activities. We may use your demographic information, such as name, address, phone number, age, gender, dates of service, department of service, treating physician or outcome information to contact you in an effort to raise money. We would release only the above information. Any fundraising communication from Franciscan Children’s will include information on how you can be removed from the contact list. You can also opt out of fundraising by contacting our Privacy Officer at the address listed at the bottom of this notice.

When is your written permission needed to use and share your information?

For any use or sharing of your PHI not described in this Notice, we need your specific and complete written permission (also called an authorization).  You may cancel any permission you’ve given at any time by submitting your written cancellation request to the same person to whom you gave your written authorization. We cannot take back any disclosure we already made with your authorization, but we will make reasonable efforts to notify persons we have shared it with of your wishes.

Certain types of highly sensitive medical information are given extra protections under Federal and State law.  We may be required under these laws to get your written permission to share the following: psychotherapy notes written and kept by your therapist, other mental health information, substance (drug and alcohol) abuse treatment information, HIV/AIDS testing, diagnosis or treatment information, and information about reproductive health issues, such as sexually transmitted diseases or pregnancy.

What are Your Privacy Rights?

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

  • Right to Inspect and Obtain a Copy. You have the right to see and get a copy of your medical information that may be used to make decisions about your care. This request usually includes medical and billing records but does not include psychotherapy notes. To see and get a copy of your medical information that may be used to make decisions about you, you must ask in writing.

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. We may deny your request to see and get a copy in certain very limited circumstances. If you are denied access to your medical information, you may ask that the denial be reviewed. Another licensed health care professional will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the result of the review. We may offer to give you a summary or explanation of the information you requested as long as you agree in advance to this and to any fees that it might cost. If you ask for information that we do not have, but we know where it is, we must tell you where to make your request. Certain information (for example, psychotherapy notes) may be withheld from you in certain circumstances.

  • Right to Amend. If you think that the medical 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 as long as we maintain the information. Your request for an amendment will become a legal part of your medical record, to be sent out along with the rest of the record whenever a request for copies is received. No part of the original documentation in the medical record can be destroyed or changed. You must make your request in writing and give the reason you want the change. We have 60 days to respond to your request. If we are not able to act on the request within the 60 days, we will notify you that we are extending the response time by 30 days. If we extend the response time, we will explain the delay to you in writing and give you a new date to expect a response.

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

  • we did not create or the person or entity that created the information is no longer available to make the amendment;
  • is not part of the medical record we maintain;
  • is not part of the information you would be permitted to inspect and copy; or
  • is accurate and complete.

If we grant the request, we will ask you to tell us the persons you want to receive the changes. You need to agree to have us notify them along with any others who received the information before corrections were made, and who may have relied on the incorrect information to give you treatment.

  • Right to Request an Accounting of Disclosures. You have the right to request an accounting of disclosures to get a list of how we have disclosed your PHI to others. The list won’t include disclosures you authorized; disclosures made for treatment, payment or healthcare operations; disclosures based on hospital directory information; disclosures for national security or law enforcement, and disclosures made before April 14, 2003. To ask for an accounting of disclosures, you must submit your request in writing.

The list will include the date, name, and address (if known) of the person or organization receiving your information. It will also include a brief description of the information given, and a brief statement of why the information was shared.

  • Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we share about you with someone who is involved in your care or the payment for your care, such as a family member or friend.

We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you. You may not ask us to restrict uses and sharing of information that we are legally required to make. To request restrictions on your medical records, you must make your request in writing.

  • Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only at home but not at work, and only by mail but not phone. To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request and we must agree to any reasonable request. At our discretion, we will accommodate all reasonable requests. Your request must tell us how or where you wish to be contacted.

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 medical 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 our hospital and on our website. The notice will contain the effective date on the first page, in the top right-hand corner. In addition, each time you register or are admitted for treatment or health care services as an inpatient or outpatient, you may ask for a copy of the notice currently in effect.

Complaints: If you believe your privacy rights have been violated, you may file a complaint directly with the Privacy Officer at 617-254-3800, extension 7723, or via email at   We respect your right to file a complaint and all complaints will be properly investigated.  If you present a complaint, your care will not be affected in any way. It is our goal to give you the best care while respecting your privacy.

You may also file a complaint with the hospital, physician practice, or with the Secretary of the Department of Health and Human Services, J.F.K. Federal Building, Room 1875, Boston, MA 02203; Phone: 617-565-1340; or email to

You will not be penalized for filing a complaint. We will take no retaliatory (punishing) action against you if you file a complaint about our privacy practices.

For more information about this notice or your rights:

If you have questions about this Notice or need help exercising your privacy rights, you can contact:

Privacy Officer
Franciscan Children’s
30 Warren Street
Brighton MA 02135
Phone: 617-254-3800, extension 7723

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To download our Notice of Privacy Practices in English, please click here.

To download our Notice of Privacy Practices in Spanish, please click here.

To download our Notice of Privacy Practices in Portuguese, please click here.