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
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