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NOTICE OF PATIENTS’ PRIVACY RIGHTS
(Effective January 1, 2018)
Please Review This Notice Carefully
A. OUR COMMITMENT TO YOUR PRIVACY: Spring Fertility (“our practice”) is committed to protecting medical, mental health and personal information about you (“Protected Health Information” or “PHI”). We are required by law to maintain the privacy of your PHI; to provide you information about our legal duties and privacy practices; and inform you of your rights and the ways in which we may use PHI and disclose it to other entities and persons. In conducting our business, we will create records regarding you and the treatment and services we provide 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 the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Patient’s Privacy Rights (“Notice”) that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information:
The terms of this notice 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 of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will provide a copy of our current Notice in our offices at all times, and you may request a copy of our most current Notice at any time.
If you have questions about this Notice, please contact our Privacy and Security Officer Derald Sue by email [email protected] or, alternatively, by telephone 415-964-5618 ext. 201.
B. HOW WE MAY USE AND DISCLOSE YOUR PHI.
1.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. The persons who work for our practice — including, but not limited to, our doctors, nurses, and other staff — may use or disclose your PHI in order to treat you or to assist others in looking after 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.
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible 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 other third parties that may be responsible for such service costs, such as benefits providers, family members, or employer-sponsored benefit providers. Finally, we may use your PHI to directly bill you for services and items. We may also disclose your PHI to other healthcare providers and entities to assist in their billing and collection efforts.
3. Healthcare Operations. We may use and disclose PHI about you for our business operations. For example, your PHI may be used to review the quality and safety of our services, or for business planning, management, training, and administrative services. We may also use and disclose your PHI to an outside company that performs services for us such as accreditation, legal, computer or auditing services. These outside companies are called “business associates” and are required by law to keep your PHI confidential. We may also disclose information to doctors, nurses, technicians, medical and other students, and other health system personnel for performance improvement and educational purposes.
4. Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
5. Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. 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.
7. Individuals Involved in Your Care or Payment for Your Care. Our practice may release PHI to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual you identify or who you involve in your treatment. We may also give information to someone who helps pay for your care.
8. Organ or Tissue Donation (Including Egg, Sperm or Embryo Donation). We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues which may include sperm, egg or embryo donation. More information can be found in our Informed consent agreements.
9. Disclosures Required by Legal Process or Law Enforcement. Our practice will use and disclose your PHI when we are required to do so by federal, state, or local law. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the healthcare system in general. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made a reasonable effort to inform you first of the request or to allow you the opportunity to obtain a protective order against such disclosure. Further, we may release PHI if asked to do so by a law enforcement official:
10. Public Health. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
11. Breach Notification. In the case of a data breach of PHI, we will notify you as required by law. We will use the contact information you provided to us in your Patient Portal to communicate information related to the breach. In some circumstances, our business associate may provide the notification. We may also provide notification by other methods as appropriate.
12. 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 written authorization is justified by any or all the following:
13. Specialized Government Functions. We may disclose your PHI for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
14. Other Methods by Written Authorization from You. Our practice may release your PHI for other reasons upon your written authorization.
C. YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communication. You have the right to request that our practice communicate with you about your health and related issues in a particular but reasonable manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will contact you at the contact information you provide to us. At any time, you may change your preferred contact information by making a written request to the Privacy and Security Officer Derald Sue by email [email protected] or, alternatively, by telephone (415) 964-5618 ext. 201, 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.
2. Requesting Restrictions. You have the right to request a reasonable 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 and Security Officer. Your request must describe in a clear and concise fashion:
3. 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 written request to the Privacy and Security 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.
4. Amendment. You may ask us to amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy and Security Officer and you must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion (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 our practice, unless for some reason the individual or entity that created the information is not available to amend the information subject to our sole discretion.
5. Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the following:
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, providing you with the opportunity to agree to such charges.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of this Notice. You may ask us to provide you with a copy of this notice at any time. In addition, you may obtain a current copy from www.springfertility.com.
7. 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, Office of Civil Rights. To file a written complaint with our practice, please contact our Privacy and Security Officer Derald Sue by email [email protected] or, alternatively, by telephone (415) 964-5618 ext. 201. You will not be penalized in any way for filing a complaint.
8. Right to Provide an 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 as permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked by you 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 PHI privacy policies, please contact our Privacy and Security Officer.
D. CHANGES TO OUR NOTICE OF PATIENT PRIVACY RIGHTS. Our practice reserves the right to change its privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current policy on our website at www.springfertility.com. In addition, at any time you may request and obtain a copy of the current Notice from us.