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AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO PARTNER
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) and California Law, this Practice may not use or disclose your individually identifiable health information except as provided in our Notice of Privacy Practices without your authorization. By completing this form, you are granting permission for the uses and disclosures below. Please review and complete this form carefully.
I, Patient Name give permission to Spring Fertility to use with and disclose to Partner Name/Patient #2 my private health information (including medical treatment, test results, billing/financial information, pregnancy, fertility, mental health, sexually transmitted infections, drug and alcohol use, and physical and/or sexual abuse). I understand that I can change and/or revoke this permission at any time.
I, Partner Name/Patient #2 give permission to Spring Fertility to use with and disclose to Patient Name my private health information (including medical treatment, test results, billing/financial information, pregnancy, fertility, mental health, sexually transmitted infections, drug and alcohol use, and physical and/or sexual abuse). I understand that I can change and/or revoke this permission at any time.
NOTICE OF CANCELLATION POLICY AND FINANCIAL RESPONSIBILITY
Spring Fertility charges a cancellation fee of $450 for all new patient consultations, and $750 for 360º Same-Day Evaluations cancelled within 72 hours of the appointment time.
Additionally, Spring Fertility charges a cancellation fee of $300 for individual counseling session, $450 for counseling session for intended parents, and $650 for donor and gestational carrier counseling session cancelled within 72 hours of the appointment time.
If you are unsure about the type of appointment you have scheduled, please call our New Patient Department at (415) 964-5618. Should a medical or family emergency arise, please let us know.
NOTICE OF PRIVACY PRACTICES
The Notice is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This Notice describes how your health information (as a patient of this Practice) may be used and disclosed, and how you can access your individually identifiable health information.
Please Review This Notice Carefully.
Our Practice is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatments and services provided to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this Notice of our legal duties and privacy practices concerning your PHI. By federal and state law, we must follow the terms of this Notice.
We are required to provide you with the following important information:
The terms of this Notice shall apply to all records containing your PHI that are created or retained by our Practice. We reserve the right to revise or amend this Notice and such revision shall be effective upon all your records our Practice has created or maintained in the past as well as for any records we may create or maintain in the future. Our Practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
The following categories describe the different ways in which we may use and disclose your PHI.
Treatment. Our Practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our Practice — including, but not limited to, our doctors and nurses — may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your PHI to other healthcare providers for purposes related to your treatment.
Payment. Our Practice may use and disclose your PHI in order to bill and collect payment for our services and any items we provide you. For example, we may contact your health insurer to certify your eligibility for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such service costs, such as family members. Also, we may use your PHI to bill you directly for service and items. We may also disclose your PHI to other healthcare providers and entities to assist in their billing and collection efforts.
Healthcare Operations. Our Practice may use and disclose your PHI to operate our business. As examples of the way we may use and disclose your information, our Practice may use your PHI to evaluate the quality of care you receive from us or to conduct cost management, operational, and business planning activities for our Practice. We may also disclose your PHI to other healthcare providers and entities to assist in their healthcare operations.
Appointment Reminders. Our Practice may use and disclose your PHI to contact you and remind you of an appointment.
Treatment Options. Our Practice may use and disclose your PHI to inform you of potential treatment options or Page 2 of 4 Form INT04 Notice of Patient Privacy Policies alternatives
Health-Related Benefits and Services. Our Practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
Disclosures Required by Law. Our Practice will use and disclose your PHI when we are required to do so by federal, state, or local law.
The following categories describe unique scenarios in which we may use or disclose your PHI:
Public Health Risks. Our Practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
Health Oversight Activities. Our Practice may disclose your PHI to a health oversight agencies for activities authorized by law. Oversight activities may include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal proceedings; or other activities necessary for governmental monitoring, licensure, or inspection, for compliance with civil rights laws, and for compliance with healthcare laws and regulations as necessary.
Lawsuits and Similar Proceedings. Our Practice may use and disclose your PHI in response to a court or administrative order, including if you are involved in a lawsuit or legal proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process as part of such proceeding.
Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
Research. Our Practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain written authorization to use your PHI for research purposes except when the Practice’s Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following:
(i) The use or disclosure involves no more than a minimal risk to your privacy based on the following:
(ii) The research could not practicably be conducted without the waiver.
(iii) The research could not practicably be conducted without access to and use of the PHI.
Serious Threats to Health or Safety. Our Practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Military. Our Practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
National Security. Upon receipt of a request, our Practice may disclose your PHI to authorized governmental officials for intelligence, counterintelligence, and other national security activities authorized by law. We will only provide this information after the Privacy Officer has validated the request and reviewed and approved our response.
Workers’ Compensation. Our Practice may release your PHI for workers’ compensation and similar programs.
You have the following rights regarding the PHI that we maintain about you:
Confidential Communication. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Privacy Officer listed below specifying the requested method of contact and/or the location where you wish to be contacted. Our Practice will accommodate reasonable requests. You do not need to give a reason for your request.
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to our Privacy Officer. Your request must describe in a clear and concise fashion:
Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Privacy Officer in order to inspect and/or obtain a copy of your PHI. Our Practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our Practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed healthcare professional chosen by us will conduct reviews.
Amendments. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for information kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to our Privacy Officer, providing us with a reason for such amendment. Our Practice may deny your requested amendment if in our opinion, it is (1) accurate and correct; (2) not part of the PHI kept by or for the Practice; (3) not part of the PHI that you would be permitted to inspect and copy; or (4) not created by us.
Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures,” which is a list of certain non-routine disclosures our Practice has made of your PHI. To obtain an accounting of disclosures, you must submit your request in writing to our Privacy Officer listed below. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our Practice may charge you for additional lists within the same 12-month period. Our Practice will notify you of other costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice. You are entitled to receive a copy of this Notice, including a paper copy, by contacting our Privacy Officer listed below.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our Practice, please contact our Privacy Officer listed below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to Provide Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable law. Any authorization you Page 4 of 4 Form INT04 Notice of Patient Privacy Policies provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note we are required to retain records of your care. If you have any questions regarding this Notice or our health information, please contact our Privacy Officer.
Privacy Officer Contact Information: Privacy Officer, Spring Fertility, 1 Daniel Burnham Court, Suite 110C, San Francisco, CA 94109, (415) 964-5618
Please Review This Notice Carefully
Information We Collect
We collect information that identifies, relates to, describes, references, is capable of being associated with, or could reasonably be linked, directly or indirectly, with a particular consumer or device (“personal information”). In particular, we have collected the following categories of personal information from consumers within the last (12) months.
Category A: Identifiers.
Examples: A real name, IP address, email address, or other similar identifiers.
Category B: Personal information categories listed in the California Customer Records Statute (Cal. Civ. Code § 1798.80(e)).
Examples: A name, signature, Social Security number, physical characteristics or description, address, telephone number, passport number, driver’s license or state identification card number, insurance policy number, education, employment, employment history, bank account number, credit card number, debit card number, or any other financial information, medical information, or health insurance information. Some personal information included in this category may overlap with other categories.
Category C: Protected classification characteristics under California or federal law.
Examples: Age (40 years or older), race, color, ancestry, national origin, citizenship, religion or creed, marital status, medical condition, physical or mental disability, sex (including gender, gender identity, gender expression, pregnancy or childbirth and related medical conditions), sexual orientation, veteran or military status, genetic information (including familial genetic information).
Category D: Commercial information.
Examples: Records of personal property, products or services purchased, obtained, or considered, or other purchasing or consuming histories or tendencies.
Category E: Biometric information.
Examples: Genetic, physiological, behavioral, and biological characteristics, or activity patterns used to extract a template or other identifier or identifying information, such as, fingerprints, faceprints, and voiceprints, iris or retina scans, keystroke, gait, or other physical patterns, and sleep, health, or exercise data.
Category F: Internet or other similar network activity.
Examples: Browsing history, search history, information on a consumer’s interaction with a website, application, or advertisement.
Category G: Geolocation data.
Examples: Physical location or movements.
Category H: Sensory data.
Examples: Audio, electronic, visual, thermal, olfactory, or similar information.
Category I: Professional or employment-related information.
Examples: Current or past job history or performance evaluations.
Category J: Non-public education information (per the Family Educational Rights and Privacy Act (20 U.S.C. Section 1232g, 34 C.F.R. Part 99)).
Examples: Education records directly related to a student maintained by an educational institution or party acting on its behalf, such as grades, transcripts, class lists, student schedules, student identification codes, student financial information, or student disciplinary records.
Category K: Inferences drawn from other personal information.
Examples: Profile reflecting the person’s preferences, characteristics, psychological trends, predispositions, behavior, attitudes, intelligence, abilities, and aptitudes.
Personal information does not include:
We obtain the categories of personal information listed above from the following categories of sources:
Use of Personal Information
Spring will not collect additional categories of personal information or use the personal information we collected for materially different, unrelated, or incompatible purposes without providing you notice.
Sharing Personal Information
Spring may disclose your personal information to a third party for a business purpose. When we disclose personal information for a business purpose, we enter a contract that describes the purpose and requires the recipient to both keep that personal information confidential and not use it for any purpose except performing the contract.
We share your personal information with the following categories of third parties:
Disclosures of Personal Information for a Business Purpose
In the preceding twelve (12) months, Spring has disclosed the following categories of personal information for a business purpose:
Category A: Identifiers.
Category B: California Customer Records personal information categories.
Category C: Protected classification characteristics under California or federal law.
Category D: Commercial information.
Disclosure of your personal information for a business purpose is limited to the following categories of third parties:
Sale of Personal Information
In the preceding twelve (12) months, Spring has not sold any categories of personal information.
Your Rights and Choices
The CCPA provides consumers (California residents) with specific rights regarding their personal information. This section describes your CCPA rights and explains how to exercise those rights.
Access to Specific Information and Data Portability Rights
You have the right to request that Spring disclose certain information to you about our collection and use of your personal information over the past 12 months. Once we receive and confirm your verifiable consumer request, we will disclose to you:
Deletion Request Rights
You have the right to request that Spring delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies.
We may deny your deletion request if retaining the information is necessary for us or our service provider(s) to:
Exercising Access, Data Portability, and Deletion Rights
To exercise the access, data portability, and deletion rights described above, please submit a verifiable consumer request to us by either:
Only you, or a person registered with the California Secretary of State that you authorize to act on your behalf, may make a verifiable consumer request related to your personal information. You may also make a verifiable consumer request on behalf of your minor child.
You may only make a verifiable consumer request for access or data portability twice within a 12-month period. The verifiable consumer request must:
We cannot respond to your request or provide you with personal information if we cannot verify your identity or authority to make the request and confirm the personal information relates to you. Making a verifiable consumer request does not require you to create an account with us. We will only use personal information provided in a verifiable consumer request to verify the requestor’s identity or authority to make the request.
Response Timing and Format
We endeavor to respond to a verifiable consumer request within forty-five (45) days of its receipt. If we require more time, we will inform you of the reason and extension period in writing. We will deliver our written response by mail or electronically, at your option.
Any disclosures we provide will only cover the 12-month period preceding the verifiable consumer request’s receipt. The response we provide will also explain the reasons we cannot comply with a request, if applicable. For data portability requests, we will select a format to provide your personal information that is readily useable and should allow you to transmit the information from one entity to another entity without hindrance, specifically by electronic mail communication.
We do not charge a fee to process or respond to your verifiable consumer request unless it is excessive, repetitive, or manifestly unfounded. If we determine that the request warrants a fee, we will tell you why we made that decision and provide you with a cost estimate before completing your request.
Personal Information Sales Opt-Out and Opt-In Rights
If you are 16 years of age or older, you have the right to direct us to not sell your personal information at any time (the “right to opt-out”). We do not sell the personal information of consumers we actually know are less than 16 years of age, unless we receive affirmative authorization (the “right to opt-in”) from either the consumer who is between 13 and 16 years of age, or the parent or guardian of a consumer less than 13 years of age. Consumers who opt-in to personal information sales may opt-out of future sales at any time.
To exercise the right to opt-out, you (or your authorized representative) may submit a request to us by emailing us at [email protected].
Once you make an opt-out request, we will wait at least twelve (12) months before asking you to reauthorize personal information sales. However, you may change your mind and opt back in to personal information sales at any time by emailing us at [email protected].
You do not need to create an account with us to exercise your opt-out rights. We will only use personal information provided in an opt-out request to review and comply with the request.
Non-Discrimination and Financial Incentives
We will not discriminate against you for exercising any of your CCPA rights. Unless permitted by the CCPA, we will not:
However, we may offer you certain financial incentives permitted by the CCPA that can result in different prices, rates, or quality levels. Any CCPA-permitted financial incentive we offer will reasonably relate to your personal information’s value and contain written terms that describe the program’s material aspects. Participation in a financial incentive program requires your prior opt in consent, which you may revoke at any time.
Other California Privacy Rights
California’s “Shine the Light” law (Civil Code Section § 1798.83) permits users of our Website that are California residents to request certain information regarding our disclosure of personal information to third parties for their direct marketing purposes. To make such a request, please send an email to [email protected] or write us at our postal address listed below.
Changes to Our Privacy Notice
Spring reserves the right to amend this privacy notice at our discretion and at any time. When we make changes to this privacy notice, we will post the updated notice on the Website and update the notice’s effective date. Your continued use of our Website following the posting of changes constitutes your acceptance of such changes.
If you have any questions or comments about this notice, the ways in which Spring collects and uses your information described above, your choices and rights regarding such use, or wish to exercise your rights under California law, please do not hesitate to contact us at:
Phone: (415) 964-5618
Email: [email protected]
ATTN: Privacy Team
1 Daniel Burnham Court Suite
110C San Francisco, CA 94109