Our policies

The Office of Privacy and Corporate Compliance is committed to providing Yale New Haven Health System, and all of its individual delivery networks, with respect to its vision, mission and values, with clear and ethical compliance direction relating to all federal and state health care program requirements and regulations.

YNHHS Code of Conduct

The YNHHS Code of Conduct is the foundation of our Compliance and Privacy Program. It outlines the duties and responsibilities of the Compliance Program and of those who are associated with and employed by Yale New Haven Health System and its affiliates.

Marna Borgstrom

Message from YNHHS President and CEO Marna P. Borgstrom

Dear Colleagues,

Yale New Haven Health System is a leader in providing safe, high-quality, comprehensive patient care. We are committed to excellent service in day-to-day interactions with our patients and their families, visitors, other staff members and the communities we serve.

We rely on our education, training and experience, but it,s our values – integrity, patient-centered care, respect, accountability and compassion – that guide us as individuals and as an organization in the work we do. In our work, often we face new and difficult situations involving issues like patient confidentiality, conflicts of interest or financial reporting. To be best positioned to address these challenges, we all need a thorough understanding of our policies, and the rules and regulations that govern our work and our actions and decisions.

The Yale New Haven Health System Code of Conduct reflects our commitment to ethical business behavior, provides guidelines for making informed decisions, and presents an overview of the policies to which we must all adhere. If you are unsure about an issue or concerned about a possible violation, your organization's corporate compliance officer will provide guidance. Or, you may call the Compliance Hotline at 1-888-688-7744 or go to the Corporate Compliance/Privacy website. Thank you for your continued commitment to providing safe, high-quality care to the patients we are privileged to serve.


Marna P. Borgstrom
YNHHS President and CEO

Why We Have a Code of Conduct

Our Code of Conduct reflects our collective commitment and responsibility to uphold our organization's reputation, practice ethical business behavior, meet rigorous professional standards, and comply with the laws, regulations and policies that govern our work. The Yale New Haven Health System (YNHHS) Code of Conduct applies to every individual affiliated with YNHHS, whether employee, volunteer, member of the medical staff or Auxiliary at YNHHS and its Bridgeport, Greenwich, Yale-New Haven and Northeast Medical Group delivery networks.

The YNHHS Code of Conduct provides:

  • An overview of the commitments that govern our work
  • Tools for reporting concerns or suspected violations without fear of retaliation
  • Guidance in making choices that may seem questionable or confusing We as individuals have a shared commitment to meeting applicable laws and industry standards and applying them to our day-to-day interactions.


The YNHHS Code of Conduct articulates our commitment to our values and ethical business behavior while reminding us that our overriding responsibility is to use sound judgment and personal integrity. It is the responsibility of each of us to understand and comply with all applicable organization policies and procedures and be able to locate them and review them periodically.

Vision Mission and Values

YNHHS Vision, Mission and Values

Corporate Compliance Program

The purpose of the Compliance and Privacy Program is to provide the system with clear ethical and compliance direction. In addition, the Compliance and Privacy Program is designed to prevent and detect violations of applicable law, Code of Conduct, and company policies.

Our Corporate Compliance Program is designed to enhance our understanding of acceptable behavior and appropriate decision-making.

It is everyone's duty to promptly report any activity that appears to violate the Code of Conduct or any laws, regulations, or organizational policies.

All YNHHS policies (including compliance and privacy) can be found on the YNHHS intranet.

Learn more about compliance

To access the Corporate Compliance Program page on the YNHHS intranet, go to Corp. Compliance/Privacy in the top navigation bar.

How to view compliance and privacy policies

To view specific Corporate Compliance policies, from the corporate compliance intranet page, click "Policies and Procedures" in the upper-left navigation box.

How to Report an Issue

  • Contact your direct supervisor.
  • Contact a higher level of management.
  • Contact Human Resources if the issue involves a human resources concern such as work conditions, discrimination or harassment, theft or abuse of property and personal security.
  • Contact the YNHHS Compliance Office (203) 688-8416 or your delivery network Compliance Officer.
  • To make an anonymous report, call the Compliance Hotline at 1-888-688-7744 or visit the Corporate Compliance/Privacy website at www.ynhhscomplianceprogramhotline.com

Calling the Compliance Hotline

If you feel uncomfortable about your activities or those of others around you and are hesitant about making a report in person, call the 24-hour Compliance Hotline at 1-888-688-7744 or make a report on the Corporate Compliance/ Privacy website at: www.ynhhscomplianceprogramhotline.com.

The hotline is outsourced to an independent company that has trained professional personnel available to speak with you. You are not required to identify yourself. The hotline is not set up for caller ID and cannot trace calls. However, you may decide to identify yourself in order to provide information that may be helpful in an investigation.

Information you provide will remain confidential to the extent possible. You will be given a case number and a call-back date. You may call back again on or after the call-back date to determine whether action has been taken, but the nature and outcome of an investigation are always confidential.

Non-retaliation for reporting

We will protect any employee who reports a concern in good faith. While you are accountable for your own wrong-doing, anyone who retaliates against you for reporting a concern in good faith will be subject to disciplinary action. Report any retaliation or harassment immediately to your supervisor, another manager, the Compliance Office or the Compliance Hotline. Please see the YNHHS Non-Retaliation and Non-Retribution for Reporting policy for more information.

Why Call the Compliance Hotline

These are just a few of the concerns that might prompt you to call the hotline:

  • Confidentiality of patient information
  • Improper billing or practices
  • Medical record cocumentation concerns
  • Conflicts of interest
  • Inappropriate use of YNHHS computers or equipment
  • Workplace safety
  • Theft
  • Any situation which places you, a patient, a co-worker or YNHHS at risk

Key Compliance Topics

Gifts & gratuities
No employee, member of the medical staff, volunteer, or member of the Board of Trustees may solicit or encourage a gift or gratuity from a patient or visitor. When gifts of a personal nature are offered by patients or visitors, they should be discouraged. The patient or visitor should be politely thanked, but told that employees, medical staff, volunteers and trustees are not permitted to accept gifts or gratuities. YNHHS personnel may never accept cash or cash equivalents, such as gift certificates or gift cards.

Gifts & business courtesies from vendors guidelines
YNHHS personnel may not offer or receive gifts unless such gifts are of a nominal value and are in accordance with these guidelines. Refer to policy on intranet for details. Under no circumstances may YNHHS personnel offer or receive a gift when the intent is to generate healthcare business. YNHHS personnel must disclose and, as appropriate, seek prior approval from their department manager when receiving or soliciting gifts as YNHHS personnel.

Minimum necessary
Employees and medical staff should request, use or disclose only the minimum amount of information necessary from patients' records, and only for patient care, billing or operations.

Employees' right to access Protected Health Information (PHI)
Employees may not use work access privileges to view the records of family members, friends, colleagues or others. Employees are granted access to electronic medical records (EMRs) for treatment, payment, or operations (TPO) purposes only.

Government exclusion from participation
YNHHS does not employ, contract with or otherwise utilize the services of any individual or organization that has been debarred or excluded from, or is otherwise ineligible to participate in, any federal healthcare program.

False claims & payment fraud prevention
All employees, contractors, agents and volunteers of YNHHS must immediately report to the delivery network Compliance & Privacy Officers or Chief Compliance & Privacy Officer any suspicion of fraud, waste or abuse in connection with the business of YNHHS. YNHHS engages in specific compliance efforts to detect and prevent fraud, waste and abuse.

Non-retaliation & non-retribution for reporting
YNHHS prohibits any acts of retribution, discrimination, harassment or retaliation against any employee who, in good faith, provides information or otherwise assists in an investigation or proceeding regarding any conduct which the employee reasonably believes to be in violation.

Compliance Examples

These are examples where the Code of Conduct can help guide your behavior:

Accessing Family Information
My mother-in-law is in the hospital and I'm a nurse working on another floor. Can I look up her lab results in Epic to see what is wrong and consult with her tonight? No. Family members, friends and co-workers are entitled to the same privacy as any other patient. You must obtain a release of information and request the records through Health Information Management (HIM) or MyChart proxy access.

Social Media
May I post something that includes the YNNHS logo or has patient information on social media? If an employee chooses to be identified as related to the System, its hospitals or other entities, he/she must make it clear to the readers that the views expressed are the employee's alone and that they do not necessarily reflect the views of the System. Employees must avoid making defamatory statements about the System or its employees, patients, clients, partners, affiliates and others, including competitors. Disclosing any protected or confidential information (e.g., patient/employee/business) on social media or online is prohibited.

Entertainment & Gifts
What if a patient gives me a gift card to my favorite store? This would not be permitted. Thank the patient and direct him or her to your delivery network's Development/ Foundation office to make a charitable contribution.

Patient Privacy
I saw a co-worker photographing a celebrity in the hospital waiting room with his phone. I didn't take the picture — do I need to report it? This is a breach of patient privacy and you are required to report it.

Patient Billing
I noticed a few instances in which the physician's office where I work was billing twice for services with a Medicare patient. Should I wait for someone to catch the error later? Billing and coding are high-risk areas and this may be considered a fraudulent claim. It should be reported immediately to your manager and/or the Compliance Department or Hotline.

Conflict of Interest
My brother sells the medical supplies we use in our office, and I do have budget authority. Do I need to disclose this? Yes. There is an easy-to-use conflict of interest tool available on Employee Self Service. If you do not have access to it, please call the Compliance Department at (203) 688-8416.

Physician Referrals
I co-own a separate physician practice and sometimes refer my patients there. Is this allowable? There are laws that regulate physician referrals; please check with Corporate Compliance and the Legal & Risk Services Department.

Will I get in trouble for reporting a possible violation? No. YNHHS has a non-retaliation policy that protects any employee who reports a concern in good faith.

Our Privacy Policies

We work hard to ensure the privacy of patients and maintain the confidentiality their information and medical records. Like all accredited healthcare institutions, we follow a federal law called the Health Insurance Portability and Accountability Act (HIPAA), which is designed to protect the privacy and confidentiality of patient information. We insist that our staff observe patient confidentiality – respecting your right to privacy about your medical records and experience at our hospital.

Authorization for Access/Release of Information

Patient Name:  (Last) (First) (Middle Initial) (Maiden/Other Name):

Date of Birth:



Complete Address (Street or Box#, City, State, Zip):

This information is to be used for purpose of: 
Self Further Medical Care Attorney Changing Physicians
Disability Workers Comp. Insurance Eligibility/Benefits

I hereby authorize Yale New Haven Health entity(ies) named below to release information from my medical record to:





Zip Code:

Method of Disclosure:

Mail Pick Up (Photo ID Required) (Date:       Time:       to be Determined by Office Staff)
Fax (Physician or Health Care Providers Only)

Please indicate records you are requesting by checking boxes below:

Yale-New Haven Hospital Hospital of Saint Raphael prior to 09/12/2012   Bridgeport Hospital Greenwich Hospital  Northeast Medical Group Smilow Care Center Cardiology Urology

Release Content: Date(s) of service requested:



History & Physical Stress Test Laboratory Results Billing Record  Discharge Summary ED Record X-ray CD Echocardiogram  Emergency Visit Progress Notes X-Ray Report Other  Procedure/Operative Report PT/OT/Speech Notes Pathology Report  Immunization Cancer Center EKG

For Internal Use Only: MRN:           CSN:        

HIV-BEHAVIORAL HEALTH- DRUG/ALCOHOL INFORMATION contained within the medical records indicated above will be released through this authorization unless otherwise indicated below. (Any records containing any of this information requires signature from age 13 and older to sign for release of records)***

Indicate which you do NOT want released with your initials:

□ HIV Substance Abuse which includes Alcohol & Drug Abuse  □ Pregnancy Test  □ Genetic Testing
□ Behavioral Health/Psychiatric □ Sexually Transmitted Disease 
□ Other (please list )

The authorization is valid for one year from the date below. I understand that after I have signed this form, I may change my mind and cancel (revoke) this authorization at any time by contacting in writing the YNHHS Medical Information Unit. Cancellation of the authorization will not apply to information that has already been released based on this authorization.

I understand the information disclosed in response to this authorization may be subject to re-disclosure by recipient, and will no longer be protected under the terms of this authorization of by federal privacy regulations.

I understand that this authorization is voluntary and my treatment by YNHHS is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. If I do not sign this form, payment for this care will only be affected if my health care insurer is requesting this information and is permitted to require this authorization.

I understand that I may see and copy the information described on this form if I ask for it. There is a charge for copies in accordance with Connecticut law.

The parent or legal guardian may sign this authorization if the patient is a minor (under age 18). If HIV, Behavioral Health, Drug/Alcohol information is included for a patient age 13 or older, the patient must sign for release of records.

Authorization can be sent to:

Medical Information Unit
PO Box 9565
New Haven, CT 06535

Printed Name:



Signature of Patient or Authorized Representative

**must provide proof of authority (except parent of a minor)

Please check relationship to patient and if other than patient, reason patient cannot sign

Self Parent Legal Guardian Executor/Administrator of Estate Healthcare Representative Conservator  Other Authorized Legal Representative (indicate) Reason:  Incompetent Disabled


I request that I be permitted to review my medical record. I understand that any amendments can be requested by doing so on the Patient Amendment Form.

Printed Name:



Patient’s Signature:

Phone (required):

You will be notified by phone for appointment time to view the medical record.

Autorización para obtener / divulgar información

Nombre del paciente:
(Apellido) (Primer nombre) (Inicial) (Apellido de soltera/otro nombre)
Fecha de nacimiento:
Dirección completa (calle o número de apartado postal, ciudad, estado, código postal)

Esta información se usará con el siguiente propósito:
 Uso propio  □ Atención médica adicional  Abogado
  Cambio de médico   Discapacidad   Indemnización por accidente laboral (workers comp)
  Elegibilidad/beneficios del seguro médico   Otro _______________________________________________

Por la presente autorizo a la(s) entidad(es) de Yale New Haven Health que aparecen a continuación para que:
  divulgue(n) información de mi expediente médico a:   obtenga(n) información de:
Código postal:

Método de divulgación:
 Correo  Pasar a recoger (Requiere identificación con fotografía)
(Fecha ________ Hora ______ la determinará el personal)
  Fax (Sólo para médicos y proveedores de cuidado de la salud)

Por favor marque la casilla correspondiente a los archivos que está solicitando:
 Yale-New Haven Hospital   Hospital of Saint Raphael, antes del 12 de septiembre de 2012  Bridgeport Hospital
 Greenwich Hospital  Northeast Medical Group  Smilow Care Center  Cardiología   Urología

Contenido de la divulgación: Fecha(s) de servicio solicitada(s):
  Historial médico y examen físico
  Informe de patología
  Centro oncológico (cancer center)
□ Electrocardiograma de esfuerzo (stress test)
□ Resumen del alta
□ Expediente de la sala de emergencias
□ Radiografías en CD
□ Resultados de pruebas de laboratorio
□ Visita a la sala de emergencias
□ Notas sobre el progreso
□ Informe de radiografías
□ Archivo de facturas
□ Informe de procedimiento /cirugía
□ Notas de fisioterapia / terapia ocupacional/terapia del lenguaje
□ Electrocardiograma (EKG)
□ Ecocardiograma
□ Registro de vacunación
□ Otro

For Internal Use Only: MRN:___________CSN: __________________________
F4918 SPAN (Rev. 04/14)

LA INFORMACIÓN SOBRE VIH - SALUD MENTAL Y DEL COMPORTAMIENTO - DROGAS/ALCOHOL que esté presente en el expediente médico mencionado anteriormente se divulgarán por medio de esta autorización, a menos que se indique lo contrario a continuación. (Cualquier registro que contenga alguna de estas informaciones requiere, para su divulgación, la autorización firmada por el paciente a partir de los 13 años de edad). ***

Ponga sus iniciales al lado de la información que desea que NO se divulgue:
□ Abuso de substancias, incluye alcohol y drogas
□ Prueba de embarazo
□ Pruebas genéticas
□ Salud mental y del comportamiento/Psiquiatría
□ Enfermedades de transmisión sexual
□ Otro (por favor indique) (________________________________)

  • Esta autorización estará vigente por un año a partir de la fecha que aparece más abaj. Entiendo que después de haber firmado este formulario, puedo cambiar de opinión y cancelar (revocar) esta autorización en cualquier momento contactando por escrito a la Unidad de Información Médica de YNHHS (YNHHS Medical Information Unit). La cancelación de la autorización no se aplicará a la información que ya se ha divulgado en base a esta autorización.
  • Entiendo que la información divulgada como resultado de esta autorización puede estar sujeta, a su vez, a divulgación por parte del receptor y ya no estará protegida bajo los términos de esta autorización o por las regulaciones federales sobre privacidad.
  • Entiendo que esta autorización es voluntaria y mi tratamiento por parte de YNHSS de ninguna manera está condicionado al hecho de que la firme o no y que me puedo rehusar a firmarla. Si no firmo este formulario, el pago por esta atención médica solamente se verá afectado si mi aseguradora de atención médica es quien solicita dicha información y está permitido que requiera esta autorización.
  • Entiendo que, si lo solicito, puedo ver y copiar la información que se describe en este formulario. De acuerdo con la ley del estado de Connecticut, se cobra una tarifa por las copias.
  • Si el paciente es menor de edad (tiene menos de 18 años), el padre, la madre o el tutor legal tienen que firmar esta autorización. Si se incluye información sobre el VIH, Salud mental, Drogas/Alcohol y el paciente tiene 13 años o más, el paciente debe firmar para que se divulguen estos archivos.

Puede enviar esta autorización a:
Medical Information Unit
PO Box 9565
New Haven, CT 06535

Nombre en letra de imprenta:
Firma del paciente o del representante autorizado

***debe proporcionar prueba de la representación (excepto si es el padre o la madre del menor)

Por favor indique su vínculo con el paciente y si no es el paciente, el motivo por el cual el paciente no puede firmar
□ Paciente □ Padre o madre □ Tutor legal □ Albacea/Administrador de los bienes □ Representante de cuidado de la salud □ Curador □ Otro representante legal autorizado (especifique):
Motivo - □ Incompetencia □ Discapacidad física

Por este medio solicito que se me permita revisar mi expediente médico. Entiendo que puedo solicitar cambios o enmiendas a través del formulario para enmiendas (Patient Amendment Form).

Nombre en letra de imprenta:
Firma del paciente:
Teléfono (obligatorio)

Yale New Haven Hospital Health System & Yale University

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact our privacy office at the phone number at the bottom of this notice.

Our pledge to you:

We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care generated by any of the separate facilities and providers described below. We are required by law to:

  • Keep medical information about you private;
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the notice that is currently in effect.

How we may use and disclose medical information about you:

We may use and disclose medical information about you without your prior authorization for treatment, such as sending medical information about you to a specialist as part of a referral (this includes psychiatric or HIV information if needed for purposes of your diagnosis and treatment); to obtain payment for treatment, such as sending billing information to your insurance company or Medicare; and to support our healthcare operations, such as comparing patient data to improve treatment methods or for professional education purposes (Note: only limited psychiatric or HIV information may be disclosed for billing purposes without your authorization). If you are treated in a specialized substance abuse program, your special authorization is required for most disclosures other than emergencies.

Other examples of such uses and disclosures include contacting you for appointment reminders and telling you about or recommending possible treatment options, alternatives, health-related benefits or services that may be of interest to you. We may also contact you to support our fundraising efforts. It is always your choice to opt out of receiving fundraising communications from us.

We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give our medical information about you, without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, medical examiners, funeral arrangements and organ donation, workers' compensation purposes, emergencies, national security and other specialized government functions, and for members of the Armed Forces as required by Military Command authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process.

Under certain circumstances, we may use and disclose health information about you for research purposes, subject to a special approval process. We may also allow potential researchers to review information that may help them prepare for research, so long as the health information they review does not leave our facility, and so long as they agree to specific privacy protection. For more information on research and how to opt out of research use of your records see www.yalestudies.org or 1-877-978-8343.

If admitted as an inpatient, unless you tell us otherwise, we will list in the patient directory your name, location in the hospital, your general condition (good, fair, etc.) and your religious affiliation, and may release all but your religious affiliation to anyone who asks about you by name. Your religious affiliation may be disclosed only to clergy members, even if they do not ask for you by name.

We may disclose medical information about you to a friend or family member whom you designate or in appropriate circumstances, unless you request a restriction. We may also disclose information to disaster relief authorities so that your family can be notified of your location and condition.

Other uses of Medical Information:

In any other situation not covered by this notice, including the use or disclosure of psychotherapy notes, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.

Who will follow this notice?

Yale New Haven Health System (YNHHS) and Yale School of Medicine (YSM) facilities provide health care to our patients in partnership with other professionals and healthcare organizations. The information privacy practices in this notice will be followed by:

  • Any healthcare professional who treats you at any of our locations
  • All departments and affiliated covered entities of Yale New Haven Health System, including; Bridgeport Hospital, Greenwich Hospital, Northeast Medical Group, and Yale-New Haven Hospital
  • Yale School of Medicine
  • The clinical care providers of Yale School of Nursing as well as their affiliates
  • All employees, medical staff, affiliates, trainees, students, or volunteers of the entities listed above

While each of these facilities and affiliates operates independently, they may share your health information for coordination of care, treatment, payment, and healthcare operations purposes.

Right to Be Notified of a Breach:

We will notify you in the event that the confidentiality of your information has been breached.

Right to Access and or Amend Your Records:

In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care. All requests for copies or access must be submitted in advance, in writing. If your request for inspection is granted, we will arrange for a convenient time and place for you to look at your record. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.

If you believe that information in your record is incorrect or that important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information is not maintained by us; or if we determine that your record is accurate. You may submit a written statement of disagreement with a decision by us not to amend a record.

Right to an Accounting:

You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, circumstances in which you have specifically authorized such disclosure and certain other exceptions. as required by law.

To request this list of disclosures, indicate the relevant period which must be within the past six years. You must submit your request in writing to the Medical Record or Billing Department as appropriate.

Right to Request Restrictions:

You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request and work to accommodate it when possible, but we are not legally required to accept it unless all of the conditions below are met:

  • You request that your information is not shared with an insurer for purposes of payment or other purposes unrelated to your treatment;
  • You pay all charges associated with the services you received out-of-pocket in full; and
  • We are not required by law to release your information to the insurer.

We will inform you of our decision on your request. All written requests or appeals should be submitted to our Privacy Office listed below.

Requests for Confidential Communications:

You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.

Right to request a paper copy of this Notice:

You may receive a paper copy of this Notice from us upon request, even if you have agreed to receive this notice electronically.

Changes to this Notice:

We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the new notice in waiting areas, exam rooms, and on our Web site at yalenewhavenhealth.org. You can receive a copy of the current notice at any time. The effective date is listed at the end. Copies of the current notice will be available each time you come to our facility for treatment. You will be asked to acknowledge in writing your receipt of this notice.


If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office listed below.

If you are not satisfied with our response, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.

YNHHS Office of Privacy and Compliance
Toll Free: 1-888-688-7744

Yale University HIPAA Privacy Office

Yale New Haven Health System Acknowledgement of Receipt of Notice Of Privacy Practices

Printed Name of Patient: 

Patient's Medical Record Number:

Patient's Date of Birth:

Patient's Address:

Patient's Personal Representative & Relationship:



If Applicable, Reason for Patient Refusal to Sign:


Yale New Haven Health System and Yale University

Aviso sobre las prácticas de privacidad

Este aviso describe cómo se puede utilizar y divulgar su información médica y de qué manera usted puede acceder a ella. Por favor lea este aviso con cuidado. Si tiene alguna pregunta, comuníquese con nuestra oficina de privacidad al número telefónico que aparece al final de este aviso.

Nuestro compromiso con usted:

Entendemos que su información médica es personal. Nos comprometemos a proteger su información médica. Para ofrecerle atención de calidad y cumplir con los requisitos legales, creamos un expediente de la atención y los servicios que recibe. Este aviso se aplica a todos estos expedientes médicos generados por cualquiera de nuestros centros y proveedores independientes mencionados a continuación. La ley nos exige:

  • Proteger la privacidad de su información médica;
  • Entregarle este aviso sobre nuestras obligaciones legales y prácticas de privacidad relacionadas con su información médica; y
  • Respetar las condiciones del aviso que se encuentre vigente.

De qué modo podemos usar y divulgar su información médica:

 Podemos usar y divulgar información médica sobre usted sin su autorización previa por razones de tratamiento, como por ejemplo enviar su información médica a un especialista como parte de un remitido (incluyendo información psiquiátrica y sobre el VIH si fuera necesario para su diagnóstico y tratamiento); para obtener el pago de un tratamiento, por ejemplo enviar información de su estado de cuenta a la compañía de seguros o a Medicare; y para apoyar nuestros servicios de atención de salud, como por ejemplo comparar datos sobre los pacientes para mejorar los métodos de tratamiento o con fines educativos para profesionales (Nota: sólo se puede divulgar sin su autorización una cantidad limitada de información psiquiátrica o sobre el VIH con el fin de facturar los servicios médicos). Si usted recibe tratamiento en un programa especializado por abuso de substancias, se requerirá su autorización especial para la mayoría de las divulgaciones que no sean por una emergencia. Otros ejemplos de tales usos y divulgaciones incluyen comunicarse con usted para recordarle que tiene una cita y mencionarle o recomendarle posibles opciones de tratamiento, alternativas, beneficios o servicios relacionados con la salud que puedan serle de interés. También podríamos comunicarnos con usted para que apoye nuestros esfuerzos para recaudar fondos. En cualquier momento, usted puede optar por no recibir información sobre nuestras campañas para recaudar fondos.
Podemos usar o divulgar información médica sin su autorización previa por varias otras razones. Podemos divulgar sin autorización previa la información médica que tenemos sobre usted, siempre que se cumplan ciertos requisitos, por razones de salud pública, denuncias de abuso o negligencia, auditorías o inspecciones de vigilancia de la salud, evaluadores médicos, arreglos funerarios y donación de órganos, por razones de indemnizaciones laborales, emergencias, seguridad nacional y otras funciones gubernamentales especializadas y para miembros de las Fuerzas Armadas según lo exigen las autoridades de Comando Militar. También divulgamos información médica cuando la ley lo requiere, como por ejemplo en cumplimiento de una solicitud de la policía en circunstancias específicas, o en respuesta a órdenes judiciales o administrativas válidas u otros procesos legales.

Podemos usar y divulgar su información con fines de investigación científica, bajo ciertas circunstancias y siempre que se cumpla un proceso de autorización especial. También podríamos permitir que potenciales investigadores analicen la información que pueda ayudarlos a prepararse para una investigación, siempre que la información médica que analicen no salga de nuestras instalaciones, y siempre que acepten cumplir con mecanismos específicos de protección de la privacidad. Para obtener más información sobre las investigaciones científicas o sobre cómo evitar el uso de su expediente para investigaciones vea la página de internet www.yalestudies.org o llame al 1-877-978-8343.

Si lo ingresan al hospital, incluiremos en el directorio de pacientes su nombre, ubicación en el hospital, su estado de salud general (bueno, regular, etcétera) y su afiliación religiosa y podremos divulgar dicha información, excepto su afiliación religiosa a cualquiera que pregunte sobre usted por su nombre, a menos que nos solicite lo contrario. Su afiliación religiosa sólo puede ser divulgada a miembros del clero, aunque no pregunten por su nombre.

Podemos divulgar su información médica a un amigo o pariente que usted haya designado o en determinadas circunstancias, a menos que usted solicite una restricción. También podemos divulgar información a las autoridades que brindan asistencia en caso de desastre para poder notificar a su familia sobre su ubicación y estado de salud.

Otros usos de la información médica:

 En cualquier otra situación que no esté contemplada en este aviso, incluyendo el uso o divulgación de las notas de las consultas de psicoterapia, solicitaremos su autorización por escrito antes de usar o divulgar información médica sobre su persona. Si usted elige autorizar el uso o la divulgación, puede revocarla más adelante notificándonos su decisión por escrito.

¿Quiénes deben seguir las normas de este aviso?

Las instalaciones de Yale New Haven Health System (YNHHS) (El Sistema de Servicios de Salud de Yale New Haven) y Yale University School of Medicine (YSM) (la Facultad de Medicina de la Universidad de Yale) brindan atención médica a nuestros pacientes, en colaboración con otros profesionales y otras organizaciones de atención de la salud. La información que contiene este aviso sobre las prácticas de privacidad será acatada por:

  • Cualquier profesional de la salud que lo atienda en cualquiera de nuestros centros.
  • Todos los departamentos y entidades afiliadas cubiertas del Yale New Haven Health System, incluyendo el Bridgeport Hospital, el Greenwich Hospital, Northeast Medical Group y el Yale-New Haven Hospital.
  • La Facultad de Medicina de la Universidad de Yale
  • El personal clínico de la Facultad de Enfermería de Yale, así como sus instituciones afiliadas.
  • Todos los empleados, el personal médico, afiliados, personal en entrenamiento, estudiantes o voluntarios de las entidades mencionadas anteriormente.
Aunque cada uno de nuestros centros y afiliados funciona de manera independiente, pueden compartir la información sobre su salud a fin de coordinar su atención médica, tratamiento, pago, y asuntos de salud.

Derecho a que se le notifique si ha habido fuga de información:

Le notificaremos si ha ocurrido alguna fuga de su información confidencial.

Derecho a obtener y rectificar su historial:

En la mayoría de los casos, usted tiene derecho a ver u obtener una copia de la información médica que usamos para tomar decisiones sobre su cuidado. Todas las solicitudes de copias del expediente médico o las solicitudes para tener acceso al mismo se deben de presentar con anticipación y por escrito. Si se le concede su solicitud, programaremos la hora y el lugar convenientes para que pueda revisar su expediente. Si solicita copias, podríamos cobrarle una tarifa por el costo del copiado, envío u otros suministros relacionados. Si denegamos su solicitud de revisar u obtener una copia, puede presentar una solicitud por escrito para que se reconsidere dicha decisión.

Si usted opina que la información que aparece en su historial es incorrecta o que falta información importante, tiene derecho a que rectifiquemos su historial presentando una petición por escrito expresando la razón por la cual ha solicitado la enmienda. Podríamos denegar su solicitud de corrección si la información no está a nuestro cargo; o si determinamos que su registro es correcto. Si nuestra decisión es no enmendar su historial, puede presentar por escrito una declaración de desacuerdo.

Derecho a recibir un informe:

Usted tiene derecho a solicitar un informe de las divulgaciones que hayamos hecho de su información de salud, excepto cuando se usó o divulgó para tratamiento, pago, servicios de atención de salud, aquellas circunstancias para las cuales haya autorizado dicha divulgación y otras excepciones según lo exige la ley.
Para solicitar esta lista de divulgaciones, indique el período relevante, que debe estar comprendido dentro de los últimos seis años. Usted debe presentar la solicitud por escrito al Departamento de Archivos Médicos (Medical Records) o al Departamento de Facturación (Billing Department), según sea apropiado.

Derecho a solicitar restricciones:

Usted puede solicitar por escrito que no usemos o divulguemos su información médica para tratamiento, pago o servicios de cuidado de la salud, o a personas involucradas en su cuidado, excepto cuando usted lo autorice específicamente, cuando lo exija la ley o en una emergencia. Consideraremos su solicitud y trataremos de ajustarnos a la misma, cuando sea posible, pero no estamos obligados por ley a aceptarla, a menos de que se cumplan todas las condiciones que aparecen a continuación:

  • Que solicite que no se divulgue su información al seguro para propósitos de pago u otros propósitos no relacionados con su tratamiento;
  • Que usted pague por su cuenta la totalidad de los cargos relacionados con los servicios que recibió; y
  • Que la ley no exija que divulguemos su información a la compañía de seguros.

Le informaremos nuestra decisión sobre su solicitud.  Todas las solicitudes y apelaciones escritas deben ser presentadas ante la Oficina de Privacidad indicada más adelante.

Solicitudes de comunicaciones confidenciales:

Usted tiene derecho a solicitar que su información médica le sea comunicada de forma confidencial como por ejemplo el envío de correspondencia a una dirección distinta a la de su hogar, notificándonos por escrito cuál es el modo específico o qué dirección debemos utilizar para comunicarnos con usted.

Derecho a solicitar una copia impresa de este aviso:

Usted puede recibir una copia impresa de este aviso si así lo solicita, aunque haya aceptado recibir este aviso por vía electrónica.

Cambios a este aviso:

Podemos cambiar nuestras políticas en cualquier momento. Los cambios serán aplicables tanto a la información médica que ya tengamos como a la nueva información que obtengamos después de ocurrido el cambio. Antes de realizar un cambio importante en nuestras políticas, cambiaremos nuestro aviso y lo colocaremos en las salas de espera, salas de examen médico y en nuestro sitio de Internet: yalenewhavenhealth.org. Usted puede recibir una copia del aviso vigente en cualquier momento. La fecha de vigencia aparece al final del mismo. Habrá copias del aviso vigente disponibles cada vez que usted visite nuestro centro para tratamiento. Se le pedirá que reconozca por escrito que recibió de este aviso.


Si a usted le preocupa que se hayan violado sus derechos de privacidad, o si está en desacuerdo con una decisión que hayamos tomado respecto al acceso a su historial, puede comunicarse con nuestra Oficina de Privacidad (indicada más adelante).

 Si no queda satisfecho con nuestra respuesta, puede enviar una queja escrita al Departamento de Salud y Servicios Humanos de los Estados Unidos, Oficina de Derechos Civiles [U.S. Department of Health and Human Services Office of Civil Rights]. Nuestra Oficina de Privacidad puede proporcionarle la dirección. Bajo ninguna circunstancia será sancionado o sufrirá represalias por presentar una queja.

YNHHS Office of Privacy & Compliance
(Departamento de Cumplimiento de Normas y Privacidad)
Número telefónico gratuito: 1-888-688-7744

Yale University HIPAA Privacy Office
(Departamento de Asesoría Jurídica,
Cumplimiento de Normas y Confidencialidad (HIPPA) de la Universidad de Yale)

Yale New Haven Health System Recibí el Aviso sobre las prácticas de privacidad

Nombre del paciente en letra de imprenta: 

No de récord médico del paciente:

Fecha de nacimiento del paciente:

Dirección del paciente:

Representante personal del paciente y vínculo:



Si corresponde, motivo por el que el paciente rehusó firmar:

F4914 (R0515)
Fecha de vigencia: 05/15/2015

Detecting and Preventing Fraud, Waste, Abuse and Misconduct

Although no precise measure of health care fraud exists, those intent on abusing the system can cost taxpayers billions of dollars while putting beneficiaries' health and welfare at risk. Medicare fraud and abuse increases the strain on the Medicare Trust Fund. The impact of these losses and risks magnify as Medicare continues to serve a growing number of people.   - CMS Medicare Learning Network

It is the policy of the Yale New Haven Health System to provide healthcare services in a manner that complies with all applicable federal and state laws. Such compliance is critical to the Health System's commitment to operating pursuant to the highest business, professional and ethical standards. In compliance with the Federal Deficit Reduction Act of 2005, YNHHS maintains a vigorous Compliance and Privacy Program and has implemented a system-wide policy regarding the detection and prevention of fraud, waste, abuse and misconduct.

Contact Us

We encourage you to call the Office of Corporate Compliance at 203-688-8416 or email us at compliance@ynhh.org to discuss any potential compliance concerns. In addition, the Compliance Hotline is available to everyone 24 hours a day, seven days a week by calling 888-688-7744 or by visiting www.ynhhscomplianceprogramhotline.com

You can make a report either anonymously or by using your name. All reports received by either the Office of Privacy amp; Corporate Compliance or the Hotline are appropriately investigated.


The purpose of this policy is to inform employees, contractors, and agents of Yale-New Haven Health System (“YNHHS”) (comprised of the Delivery Networks: Yale-New Haven Hospital, Bridgeport Hospital, Greenwich Hospital and Northeast Medical Group) of the Federal False Claims Act (referenced in this policy as "FCA") the Federal Program Fraud Civil Remedies Act, the Connecticut False Claims Act (“CFCA”), and all other State False Claims Acts; to provide general information regarding YNHHS’s efforts to combat fraud, waste, and abuse; and to describe the remedies and fines for violations that can result from certain types of fraudulent activities.


Reporting Fraud, Waste, or Abuse
All employees, contractors, agents, and volunteers of YNHHS must immediately report to the Delivery Network Compliance & Privacy Officers or Chief Compliance & Privacy Officer, any suspicion of fraud, waste, or abuse in connection with the business of YNHHS. YNHHS engages in specific compliance efforts to detect and prevent fraud, waste, and abuse, such as the Corporate Compliance Program.

If you would like more information on the Corporate Compliance Program and specific compliance policies or on how to report any concerns, please contact the Office of Privacy and Corporate Compliance (203-688-8416). Compliance Policies may also be accessed via the YNHHS Intranet.

Detailed Information of the Federal False Claims Act
The Federal False Claims Act (FCA) imposes civil penalties on people and companies who knowingly submit a false claim or statement to a federally-funded program or otherwise conspire to defraud the government in order to receive payment. Failure to report and return overpayments from Medicare and Medicaid within certain timeframes might also constitute a violation of the FCA. The FCA also protects people who make efforts to stop the suspected fraud.

The FCA is not confined to healthcare claims, but extends to any payment requested of the federal government or the federal government’s contractor, grantee, or other party, if the payment is to be spent or used on the government’s behalf or to advance a government program or interest and the government provides any portion of the payment or will reimburse the contractor, grantee, or other party. The FCA applies to billing and claims sent from YNHHS to any government payor program, including Medicare and Medicaid.

It is the policy of YNHHS that an employee, contractor, or agent of YNHHS who knowingly and intentionally submits a false claim will be reported to the necessary authorities. Anyone or any company that submits a false claim or statement to the government may be fined under the FCA between $5,500 and $11,000 for each such claim submitted, regardless of the size of the false claim, and the person or company could be required to pay an additional fine of three times the value of any charges.

Part of the FCA's purpose is to create an environment where employees and others feel safe reporting concerns about fraud. Any person who lawfully attempts to stop any FCA violations or reports information about false claims or suspected false claims that are submitted by others, may not be retaliated against, demoted, suspended, threatened, or harassed for such actions. The FCA also protects individuals who assist in an investigation, provide testimony, or participate in the government's handling of a false claim. The FCA’s provisions are generally enforced by the U.S. Department of Justice. The FCA provides that a person may initiate a formal claim under certain circumstances. If any funds are recovered, a portion of the funds may be paid to the person who initiated the formal claim, at the discretion of a federal court. This amount, if awarded, generally is between 15% and 30% of the total damage amount. If a person wishes to file a claim regarding fraud or suspected fraud related to a healthcare payment directly with the government, he or she must first present a formal complaint, along with all material evidence relating to the alleged fraud, to the authorities at the U.S. Department of Justice. The authorities have 60 days to investigate, during which time the complaint is kept confidential. Upon completion of the investigation, the government will decide either to pursue the case on its own or decline to proceed with the case. If the federal government declines the case, the individual may still proceed with the case on his or her own, but without the government's assistance, and at his or her own expense.

A private legal action under the FCA must be brought within six years from the date that the false claim was submitted to the government. (A government-initiated claim may be brought up to ten years after the false claim, depending on the circumstances.)

Detailed Information of the Federal Program Fraud Civil Remedies Act

Persons or companies that commit fraud on the federal government, by false claim or statement, can be assessed monetary penalties in addition to the penalties of the False Claims Act because of a law called the Program Fraud Civil Remedies Act (referenced in this policy as "PFCRA"). Specifically, PFCRA penalties of $5,000 per false claim or statement apply if a person or company submits a claim to the federal government that: the person or company knows or has reason to know is false, fictitious, or fraudulent; includes or is supported by written statements containing false, fictitious, or fraudulent information; includes or is supported by written statements that omit a material fact, which causes the statements to be false, fictitious, or fraudulent and the person submitting the statement has a duty to include the omitted fact; or is for payment of property or services that are not provided as claimed.

The $5,000 penalty also applies if a person or company provides written back-up or materials relating to the claim in which the person or company asserts a material fact that is false, fictitious, or fraudulent; or omits a fact that the individual had a duty to include, the omission causes the statement to be false, fictitious, or fraudulent, and the statement contains a certification of accuracy.

Connecticut State Law
In 2009, the Connecticut General Assembly enacted the Connecticut False Claims Act (“CFCA”). The CFCA is very similar to the FCA and prohibits any individual or entity from knowingly presenting or causing to be presented a false or fraudulent claim for payment or approval under the medical assistance programs administered by the Connecticut Department of Social Services or knowingly making or causing to be made a false statement in order to get such a claim approved, or knowingly concealing, avoiding, or decreasing any obligation to pay or transmit money or property to the state. Any individual or entity that violates this prohibition can be subjected to civil monetary penalties of $5,000 to $10,000 per violation as well as up to three times the damages sustained by the state as a result of the false claim.

The CFCA provisions are generally enforced by the Connecticut Attorney General. However, like the FCA, under certain circumstances, the CFCA permits private individuals to initiate civil actions and protects these individuals from workplace retaliation. If any funds are recovered, a portion of the funds may be paid to the person who initiated the formal claim, at the discretion of a court. This amount, if awarded, general is between 15% and 30% of the total damage amount. A legal action under the CFCA cannot be initiated more than six years after the date the violation occurs or more than three years after the date when a state official knew or should have reasonably known the violation, but in no event more than ten years after the date that the violation occurs.

In addition, there are also other Connecticut laws that prohibit fraudulent billing. It is a crime in Connecticut to fraudulently bill Medicaid or general assistance programs. All employees, contractors, and agents of YNHHS must immediately report suspicion of any criminal activity, including criminal fraud, to the System Compliance and Privacy Officer.

Anyone who provides services to a state Medicaid beneficiary and seeks or accepts payment for unnecessary or improper services is subject to possible imprisonment and/or criminal fines under state law. Depending upon the extent of the fraudulent services involved, such offenses carry potentially significant penalties, with a maximum of 20 years in prison and a maximum fine of $15,000.

Anyone who provides services to a recipient of Connecticut's general assistance program and seeks or accepts payment for unnecessary or improper services is also subject to civil and criminal penalties. Depending upon the amount of the fraudulent services involved, such offenses carry a minimum one-year prison sentence and a maximum of 20 years, as well as a maximum fine of $15,000. Any person who defrauds Connecticut's general assistance program is also excluded from participating in the program for a minimum of one year.

Connecticut law protects employees who report suspected violations of state or federal law, including reports of criminal fraud. An employer may not discharge, discipline, or otherwise penalize an employee for reporting a violation of the law, or suspected violation, as long as the employee does not know the information being reported is false.

YNHHS is dedicated to creating an environment where employees and others feel safe reporting concerns about fraud. YNHHS shall not unlawfully retaliate against individuals who: lawfully attempt to stop fraudulent billing practices or violations of the FCA, CFCA, or any other federal or state law or regulation regarding false or fraudulent claims; report information about false claims or suspected false claims the are submitted by YNHHS; or assist in any investigation, provides testimony, or participate in the government’s handling of a false claim investigation.

References and Related Policies

Relevant Connecticut Laws and Regulations
  • Connecticut General Statutes § 4-61dd (Whistle blowing)
  • Connecticut General Statutes § 17b-25a (Toll Free Vendor Fraud Telephone Hotline) Connecticut General Statutes § 17b-99 (Vendor Fraud)
  • Connecticut General Statutes § 17b-102 (Financial Incentive for Reporting Vendor Fraud) Connecticut General Statutes § 17b-127 (General Assistance Fraud)
  • Connecticut General Statutes § 17b-301a et seq. (Connecticut False Claims Act)
  • Connecticut General Statutes § 31-51m (Protection of Employee Who Discloses Employer's
  • Illegal Activities or Unethical Practices)
  • Connecticut General Statutes § 31-51q (Liability of Employer for Discipline or Discharge of
  • Employee on Account of Employee's Exercise of Certain Constitutional Rights) Connecticut General Statutes § 53-440 et seq. (Health Insurance Fraud) Connecticut General Statutes § 53a-118 et seq. (Larceny)
  • Connecticut General Statutes § 53a-155 (Tampering with or Fabricating Physical Evidence) Connecticut General Statutes § 53a-157b (False Statement Intending to Mislead Public Servant)
  • Connecticut General Statutes § 53a-290 et seq. (Vendor Fraud)
  • Regulations of Connecticut State Agencies § 4-61dd-1 et seq. (Rules of Practice for
  • Contested Case Proceedings under the Whistleblower Protection Act)
  • Regulations of Connecticut State Agencies § 17-83k-1 et seq. (Administrative Sanctions) Regulations of Connecticut State Agencies § 17b-102-01 et seq. (Financial Incentive for Reporting Vendor Fraud and Requirements for Payment for Reporting Vendor Fraud)
Relevant New York State Laws and Regulations
  • New York State Finance Law §§187-194
  • New York State Social Services Law, Title 1 §145b (False Statements)
  • Relevant Massachusetts Laws and Regulations
  • MassHealth Regulation 130 CMR 450.205(F) (1)
  • MassHealth Regulation 130 CMR 450.223(C) (7)
Federal Law Cross References
  • Section 6032 of the Deficit Reduction Act of 2005
  • 31 U.S.C. §§ 3729-3733 (Federal False Claims Act)
  • 31 U.S.C. §§ 3801-3812 (Administrative Remedies for False Claims and Statements)
  • Yale New Haven Health System Cross References Yale New Haven Health System Code of Conduct
  • CC: R-8, Corporate Compliance Program
  • CC: R-2, Corporate Compliance Hotline
  • CC: R-3, Exclusions and Background Checks
  • CC: R-4, Exit Interviews
  • CC: R-6, Non-Retaliation and Non-Retribution for Reporting
  • CC: R-11, Identifying, Tracking and Processing Overpayments Policy

: Compliance - General
Yale New Haven Health System: Yale-New Haven Hospital / Bridgeport Hospital / Greenwich Hospital / Northeast Medical Group
Title: False Claims and Payment Fraud Prevention
Policy Number: CC:R-9
Formerly CC:R-33
Date Originated: 1-1-07
Approved by: YNHHS Compliance Committee
Date Reviewed: 8-21-07, 7-16-09, 6-10-10, 3-4-11
Date Revised: 12-2012
Distribution: YNHHS Intranet Policies – Corporate Compliance
Policy Type: I
Supersedes: None

Vendor Policy

Yale New Haven Health System Supply Chain Management staff is focused on working with vendors to deliver high-quality supplies, services and equipment, at the lowest total cost. Click here to learn more about our vendor policy.


To provide guidelines that give Vendor Representatives an opportunity to conduct business in a manner that does not interfere with the normal operations of Yale New Haven Health Services Corporation and its affiliates (“YNHHS”), to enhance patient care quality and safety, respect for the confidentiality of information and to ensure a cost effective procurement system that complies with YNHHS contractual and ethical policies and standards while fostering an environment of fair competition with vendor access and control.


A. Policy

It is the policy of YNHHS that the conducting of business with vendor representatives be initiated and managed through the locally based facility’s Supply Chain Management personnel and YNHHS Corporate Supply Chain Management Department, with special emphasis on all HIPAA requirements to safeguard the privacy and confidentiality of patient health information.

B. Standard Procedures

1. All Vendor representatives wishing to conduct business at YNNHS facilities must do so through the Supply Chain Management Department, Pharmaceutical Department, Food Services Department or Facilities/Construction Department. Vendors who have been authorized as YNHHS business partners by one of these departments and Supply Chain Management, may conduct business, by appointment, with the respective departments, and in accordance with the policy set forth below. Representatives who attempt to conduct business directly with hospital departments or staff without prior authorization of Supply Chain Management and an appointment will be immediately redirected to the Supply Chain Management Department by the affected department and be considered in breach of this policy.

2. Vendor Representatives are individuals who market products and services to YNHHS facilities. All Vendor representatives must be fully registered and signed in to the “Vendor Mate” vendor management system upon each visit to the hospital. Representatives are not allowed to conduct business at YNHHS without full registration in the Vendor Mate System. When fully registered and upon signing into the system upon each visit, the Vendor representative will then be allowed to print a vendor badge with photo ID, that must be worn visibly on a part of the clothing located above the waist. Those representatives who are witnessed not wearing a badge will be questioned by hospital personnel, advised of the policy and immediately referred to the facility’s Procurement Coordinator or other Supply Chain Management personnel.

3. Vendor representatives are required to adhere to YNHHS policies including but not limited to: HIPAA Policies, The Gifts and Gratuity Policy (CC:R-20), Gifts and Business Courtesies from Vendor Policy (CC:R-35) and the YNHHS Code of Conduct. Pharmaceutical representatives are required to adhere to the YNHHS Pharmaceutical Vendor Policy (Exhibit 1).

4. Vendor representatives will not be allowed to conduct business on YNNHS property after 5:00 pm. unless prior arrangements have been made for such activities such as product fairs/demonstrations, in-service programs, or service / repair work.

5. New products that are introduced will need prior approval / determination of pricing and YNHHS contractual adherence through the Supply Chain Management personnel. The Supply Chain Management Department in collaboration with the requesting department will direct new product introduction through the appropriate hospital and/or Health System committee structure/approval process. Trials for new product will require prior authorization through the completion and approval of the “New Product Request” form. The request and the form must be generated from a Hospital or Health System employee or a physician and may not be completed by a vendor representative. At a minimum, the request form will be signed by the user department as well as a member of the Supply Chain Management department for the respective facility or the Health System. New items introduced that would potentially be used by several departments (such as commodity type products) will require review by each facility’s Product Evaluation Committee before a trial is granted.

C. Violation of Vendor Policy

In the event that a member of the YNHHS staff observes a Vendor or Vendor Representative in violation of policy, the staff member should immediately notify the Supply Chain Management Department. YNHHS reserves the right to investigate any violations and based upon the severity of the violation shall determine disciplinary action and communicate such actions to the system hospitals as needed.

  1. Verbal and/or written warning to the vendor representative and his/her supervisor.
  2. Restriction of all activity and service calls at any YNHHS location for 3 months, 6 months, or 1 year depending on infraction. 
  3. Violations committed by any one representative of a given company may result in disciplinary action against any or all representatives of that company.

Repeated Violations by any Vendor or Representative may result in the banning of future visitations by Vendor or a particular Representative for a one year period or indefinitely if warranted.

Exhibit I

Yale-New Haven Health System

Guidelines for Pharmaceutical Company Representatives

Definition: Pharmaceutical Company Representative

A Pharmaceutical Company Representative (PCR) shall be defined as a representative of a pharmaceutical company who enters Yale-New Haven Health System (YNHHS) to promote the use of products/services which are evaluated and/or purchased by the Department of Pharmacy Services.

Refer to hospital–specific PCR policy for a more detailed guideline.

General Code of Conduct for Pharmaceutical Company Representatives

  • Any PCR who wishes to access YNHHS facilities and be eligible for business with YNHHS must register in our vendor credentialing and compliance monitoring system (Vendormate). 
  • Upon Vendormate registration, PCR must read and acknowledge acceptance of the YNHHS PCR guidelines as well as any site specific procedures annually.
  • All PCRs visiting YNHHS must sign in and out at one of the Vendormate Kiosk locations.
  • PCRs shall display Vendormate-generated identification badges at all times.
  • The PCR must make an appointment with the secretary or designee of the hospital employee with whom they wish to speak PRIOR to conducting business with that individual.
  • PCRs may not be present in patient care areas at any time. Approved appointments must be held in a location that does not require travel through a patient care area.
  • PCRs may not use inter-hospital phones, paging system or inter-hospital mail systems.
  • P&T and its sub-committee members shall not be specifically targeted by PCRs regarding product information or Committee business items.

Disbursement of Drug Information

  • PCRs shall first inform the Department of Pharmacy Services of new drugs they wish to discuss at YNHHS.
    —  Information changes pertaining to medications on formulary (i.e. indications, dosage, routes of administration, formulations, etc.) shall be provided to the Department of Pharmacy Services prior to discussion with other YNHHS personnel.
  • All pharmaceutical detailing shall be within the context of P&T approved criteria for restricted drugs, as it relates to the specific hospital.
    —  PCRs shall limit discussions of restricted drugs with those authorized to prescriber as noted in the P&T approved criteria and designated pharmacy staff.
  • At no time shall PCRs detail non-formulary drugs or indications not included in the YNHHS criteria or specific hospital criteria without approval from the Director of Pharmacy Services or his/her designee.
    —  Non-formulary categories include the following: drugs not yet reviewed by the P&T Committee, drugs reviewed and denied addition, and off-criteria indications of restricted formulary drugs.
  • All information and materials distributed at YNHHS must be approved by the Director of Pharmacy Services or his/her designee prior to distribution.
  • Product package inserts and peer-reviewed journal articles that are not company labeled may be distributed only when attached to the YNHHS Criteria for Use to highlight differences between FDA approved indications and YNHHS approved indications. 

Educational Activities

PCRs are not permitted to attend or provide educational in-services at YNHHS unless prior approval is obtained by the Director of Pharmacy Services or his/her designee. 

  • PCRs may not post and YNHHS will not advertise industry-sponsored events that are not CME/CE accredited or fail to comply with the Yale School of Medicine Conflict of Interest Policy, Accreditation Council for Continuing Medical Education (ACCME), or Accreditation Council for Pharmacy Education (ACPE) standards.

Violation of Guidelines

  • Violations of PCR guidelines shall be reported to the respective Director of Pharmacy Services.
  • Based on the severity of the violation, the Director of Pharmacy Services or his/her designee shall determine disciplinary action and communicate to the system hospitals as needed.
  • The Director of Pharmacy Services shall impose one or more of the following restrictions on an PCR found to be in violation of the guidelines:
    — Verbal and/or written warning to the PCR and his/her supervisor.
    — Restriction of all activity and service calls at any YNHHS location for 3 months, 6 months, or 1 year depending on infraction.
    — Letters to the PCR, his/her supervisor, and to the Vendor Director of the pharmaceutical company stating that the PCR is no longer permitted on the hospital and/or YNHHS premises for a specified time frame.
  • Violations committed by any one representative of a given company may result in disciplinary action against any or all representatives of that company.
  • Document Information

SC I - 001 Vendor Visitation

Document Description
To provide guidelines that give Vendor Representatives an opportunity to conduct business in a manner that does not interfere with the normal operations of Yale New Haven Health Services Corporation and its affiliates (�YNHHS�), to enhance patient care quality and safety, respect for the confidentiality of information and to ensure a cost effective procurement system that complies with YNHHS contractual and ethical policies and standards while fostering an environment of fair competition with vendor access and control.

Approval Information
Approved On: 07/31/2013
Approved By: Pamela Scagliarini, VP SCM
Approval Expires: 07/31/2016
Approval Type: Manual Entry
Document Location: / YNHHS - Supply Chain Management
Keywords: Vendor Visitation
Printed By: Guest User
Standard References: N/A