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
, hereafter referred to as just (“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.
Consent to display photography: All printed
photographs mailed to our office by patients, and/or photos submitted
electronically (jpeg image etc.) by patients, may be displayed in our office or
on our social media venues (website, Facebook, Twitter etc.). If patients do
not want their photo(s) displayed in office or on social media, a written
notification must be submitted at the time photo(s) are received. All
photos received from patients become the property of lnVia
Fertility and may be disposed via secure document shredding.
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 however, 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 's privacy
officer. If you have any questions about this Notice, please
contact us at the .