NOTICE
OF PRIVACY PRACTICES
THIS
NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We will also be obtaining your written
acknowledgement that you had the opportunity to review this Notice of Privacy
Practices (“Notice”). This Notice
applies to Fertility Center, hereafter referred to as just Fertility Center(“we”
or “us”).
We are
required by applicable federal and state law to maintain the privacy of your
PHI. We are also required to give
you this notice about our privacy practices, our legal duties, and your rights
concerning your PHI. We must follow
the privacy practices that are described in this notice while it is in
effect. This notice took effect
April 14, 2003, and will remain in effect until we replace it.
We use
and disclose PHI about you for treatment, payment and health care
operations. For example:
Treatment: We may use your PHI to
treat you or disclose your PHI to a physician or other health care provider
providing treatment to you. We may
disclose your PHI to doctors, nurses, hospital medical staff, pharmacists, or
other support personnel involved in your care.
Payment: Your PHI may be used or
disclosed by us to bill and/or collect payment for treatment and services
provided to you.
Health
Care Operations: We may use or disclose your PHI in
conjunction with our health care operations. Health care operations include, but are
not limited to, licensing or credentialing physicians and ancillary staff,
reviewing the qualifications and/or competence of health care professionals,
evaluating staff performance, conducting training programs, quality assessment
and improvement programs.
To You and on Your Authorization: You may give us written
authorization to use your PHI or to disclose it to anyone for any purpose. You may also revoke this authorization
in writing at any time. This
written revocation will not affect any use or disclosures of your PHI permitted
by your original written authorization while it was in effect.
Individuals
Involved in Your Care or Payment for Your Care: Upon receiving your
authorization, your PHI may be disclosed to a family member, friend or other
person involved in your care or payment of your medical care. Since the nature of infertility is to
generally treat the couple, your PHI will be shared with your partner, unless
you request, in writing, for your PHI to not be shared with your partner. If you are a non-infertility patient,
whose parents may be paying for your medical care, we will not disclose your
confidential PHI to them without your written authorization.
Appointment
Reminders: We may use your PHI to contact you to
provide appointment reminders, by telephone, in writing or via secure email.
Research: We may use or disclose your
PHI for research purposes in limited circumstances. You will be asked for your written
permission if your PHI that specifically identifies you will be used or
disclosed in the research project.
USES
AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION (PHI)
We may
use or disclose your PHI for law enforcement purposes or in response to a valid
subpoena.
Public Health
Risks: We may disclose your PHI for Public
Health Activities including to prevent or control disease, injury or
disability; to notify a person who may have been exposed to a communicable
disease or may be at risk for contracting or spreading a disease or condition;
to report adverse reactions to medications or problems with products; to report
to the appropriate government authority if we believe a patient has been the
victim of abuse, neglect or domestic violence.
Health
Oversight Activities: We may disclose your PHI to a health
oversight agency for activities authorized by law, including audits,
investigations, inspections, accreditation and/or licensure.
Lawsuit
and Disputes: We may disclose your medical information
in response to a subpoena or court order, if you are involved in a lawsuit or a
dispute, only if efforts have been made to tell you about the request or to
obtain an order protecting the information requested, if that is required by
law.
Law
Enforcement: We will release your medical information
if requested by a law enforcement official, if either a valid authorization
from you is provided, or a court subpoena requires such a release.
Uses
and Disclosures for Specialized Government Functions: The practice uses and discloses PHI for military and veteran’s
activities, national security and intelligence activities, and other activities
as required by law.
Uses and Disclosures – Do Not Apply to Practice
Other
Uses and Disclosures: The practice
does not use or disclose PHI to employers or health plan sponsors, for
underwriting and related purposes, for facility directories, or to brokers and
agents, or for fundraising. If an
individual wants the practice to release his or her PHI to employers or health
plan sponsors, for underwriting and related purposes, for facility directories,
or to brokers and agents, then he or she can contact the practice and complete
an appropriate written authorization.
YOUR
INDIVIDUAL RIGHTS REGARDING YOUR PROTECTED MEDICAL INFORMATION (PHI)
Your
medical record is the physical property of the Practice of Fertility Centerhowever,
the information within your medical record belongs to you. You have the right to:
Right
to Inspect and Copy: You have the right to inspect and copy
medical information that may be used to make decisions about your care. To do so, you must submit your request
in writing to the address at the end of this notice. If you request copies, we will not
charge you for the first copy, but will charge you $25.00 for copies
thereafter, and postage if you want the copies mailed to you.
Right
to Amend: You have the right to request that we
amend your medical information.
Your request must be in writing, and it must explain why the information
should be amended. We may deny your
request if it is not in writing or does not include a reason. We may deny your request for an
amendment of your medical information if we were not the originator of the
medical information, or if your medical information is accurate and complete.
Right
to Request Restrictions: You have the right to request that we
restrict the use or disclosure of your medical information. We are not required to agree to your
request. If we do agree, we will
comply with your request unless your medical information is needed to provide
you emergency care. To request
restrictions, you must do so in writing.
Your request must state what information you want us to limit, whether
you want to limit or use, disclosure or both, and to whom you want the limits
to apply.
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. You must make this
request in writing. We will not ask
the reason for your request. We will
make every effort to accommodate all reasonable requests.
Right
to an Accounting of Disclosures: You have the right to request a list of
certain disclosures of your medical information made by us since April 14,
2003. Such disclosures will not
include those made for purposes of treatment, payment or healthcare operations
or disclosures to you or authorized by you.
Right
to Complain: If you believe your privacy rights have
been violated, or you disagree with a decision we made about access to your medical
information or in response to a request you made to amend or restrict the use
or disclosure of your medical information or to have us communicate with you in
a certain way or at a certain location, you may complain to us using the
contact information at the end of this notice. You may also submit a written complaint
to the U.S. Department of Health and Human Services. We will not retaliate in any way if you
choose to file a complaint.
Right
to a Paper Copy of this Notice: You have the right to receive a paper
copy of this Notice. You may ask
for a copy of this notice at any time.
CONTACT INFORMATION: The practice has a privacy officer that serves as the contact person for all issues related to the Privacy Rule. Please contact the practice directly to obtain the name and contact information of Fertility Center's privacy officer. If you have any questions about this Notice, please contact us at the Fertility Center.