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.
I. What this Is
This Notice describes the privacy practices of Delaware Valley Institute of Fertility & Genetics.
II. Our Privacy Obligations
We are required by law to maintain the privacy of medical and health information about you (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to PHI. When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
A. Use and Disclosure With For Treatment, Payment and Health Care Operations. We may use and disclose PHI (including, if any, your HIV/AIDS related, venereal disease or tuberculosis information) in order to treat you, obtain payment for services provided to you and conduct our “health care operations” (e.g., internal administration, quality improvement and customer service) as detailed below:
• Treatment. We use and disclose PHI to provide treatment and other services to you–for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
• Payment. We may use and disclose PHI to obtain payment for services that we provide to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”), or to verify that Your Payor will pay for health care.
• Health Care Operations. We may use and disclose PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.
We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
B. Disclosure to Relatives, Close Friends and Other Caregivers.We may use or disclose PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure. If you object to such uses or disclosures, please notify the Office Manager.
If you are not present, you are incapacitated, or in an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
C. Public Health Activities. We may disclose PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; and (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
E. Health Oversight Activities. We may disclose PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
G. Law Enforcement Officials. We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
H. Decedents. We may disclose PHI to a medical examiner as authorized by law.
I. Organ and Tissue Procurement. We may disclose PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
J. Research. We may use or disclose PHI without your consent or authorization if an Institutional Review Board/Privacy Board approves a waiver of authorization for disclosure.
K. Health or Safety. We may use or disclose PHI to prevent or lessen a threat of imminent, serious physical violence against you or another readily identifiable individual.
L. Specialized Government Functions. We may use and disclose PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances required by law.
M. Workers’ Compensation. We may disclose PHI as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
N. As required by law. We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.
IV. Use and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described in Section III, we only may use or disclose PHI when (1) you give us your authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before we can send PHI to your life insurance company, to your child’s camp or school, or to the attorney representing the other party in litigation in which you are involved.
B. Marketing Communications. We must also obtain your written authorization (“Your Marketing Authorization”) prior to using PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter, without obtaining Your Marketing Authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.) In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. We may use or disclose PHI to identify health-related services and products that may be beneficial to your health and then contact you about the services and products.
C. Genetic Information. Except in certain cases (such as a paternity test for a court proceeding, anonymous research, newborn screening requirements, or pursuant to a court order), we will obtain your special written consent prior to obtaining or retaining your genetic information (for example, your DNA sample) or using or disclosing your genetic information for purposes of treatment, payment or health care operations. We may use or disclose your genetic information for any other reason only when Your Authorization expressly refers to your genetic information or when disclosure is permitted under New Jersey State law (including, for example, when disclosure is necessary for the purposes of a criminal investigation, to determine paternity, newborn screening, identifying your body or as otherwise authorized by a court order).
D. HIV/AIDS Related Information. Your Authorization must expressly refer to your HIV/AIDS related information in order to permit us to disclose your HIV/AIDS related information. However, there are certain purposes for which we may disclose your HIV/AIDS information, without obtaining Your Authorization: (1) your diagnosis and treatment; (2) scientific research; (3) management audits, financial audits or program evaluation; (4) medical education; (5) disease prevention and control when permitted by the New Jersey Department of Health and Senior Services; (6) to comply with a certain type of court order; and (7) when required by law, to the Department of Health and Senior Services or another entity. You also should note that we may disclose your HIV/AIDS related information to third party payors (such as your insurance company or HMO) in order to receive payment for the services we provide to you.
E. Venereal Disease Information. Your Authorization must expressly refer to your venereal disease information in order to permit us to disclose any information identifying you as having or being suspected of having a venereal disease. However, there are certain purposes for which we may disclose your venereal disease information, without obtaining Your Authorization, including to a prosecuting officer or the court if you are being prosecuted under New Jersey law, to the Department of Health and Senior Services, or to your physician or a health authority, such as the local board of health. Your physician or a health authority may further disclose your venereal disease information if he/she/it deems it necessary in order to protect the health or welfare of you, your family or the public. Under New Jersey law, we may also grant access to your venereal disease information upon the request of a person (or his/her insurance carrier) against whom you are asserting a claim for compensation or damages for your personal injuries.
F. Tuberculosis Information. Your Authorization must expressly refer to your tuberculosis information in order to permit us to disclose any information identifying you as having tuberculosis or refusing/failing to submit to a tuberculosis test if you are suspected of having tuberculosis or are in close contact to a person with tuberculosis. However, there are certain purposes for which we may disclose your tuberculosis information, without obtaining Your Authorization, including for research purposes under certain conditions, pursuant to a valid court order, or when the Commissioner of the Department of Health and Senior Services (or his/her designee) determines that such disclosure is necessary to enforce public health laws or to protect the life or health of a named person.
V. Your Individual Rights
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to PHI, you may contact our Office Manager. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Office Manager will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. All requests for such restrictions must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Office Manager and submit the completed form to the Office Manager. We will send you a written response.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable [written] request for you to receive PHI by alternative means of communication or at alternative locations.
D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, please obtain a record request form from the Office Manager and submit the completed form to the Office Manager. If you request copies, we will charge you [$1.00] for each page or $100 for the entire record, whichever is less, as permitted by New Jersey law. We will also charge you for our postage costs, if you request that we mail the copies to you.
You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records relating to pregnancy, abortion, sexually transmitted disease, substance use and abuse, and contraception and/or family planning services).
E. Right to Revoke Your Authorization. You may revoke Your Authorization or Your Marketing Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Office Manager identified below. [A form of Written Revocation is available upon request from the Office Manager.]
F. Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Office Manager and submit the completed form to the Office Manager. All requests for amendments must be in writing. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you [$0.__ per page] of the accounting statement.
H. Right to Receive Paper Copy of this Notice. Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in waiting areas of the Practice [and on our Internet site at www.startfertility.com. You may also obtain any revised notice by contacting the Office Manager.
VII. Office Manager
You may contact the Office Manager at:
Delaware Valley Institute of Fertility & Genetics
6000 Sagemore Drive – Suite 6102
Marlton, New Jersey 08053
Telephone: (856) 988-0072
Fax: (856) 988-0056