Understanding what is in your health records and how your health information is used helps you to:

• Ensure its accuracy and completeness.
• Understand who, what, where, why, and how others may access your health information.
• Make informed decisions about authorizing disclosure to others.
• Better understand the health information rights detailed below.

Your Rights Under the Federal Privacy Standard

Although your health records are the physical property of the healthcare provider who completed it, you have certain rights with regard to the information contained therein. You have the right to:

• Request a restriction on uses and disclosures of your information for treatment, payment, and healthcare operations. "Healthcare operations" consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under 164.502(a)(2)(i) (disclosures to you), 164.510 (a) (for facility directories, but note that you have the right to object to such uses), or 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, like mandatory communicable disease reporting. In those cases, you do not have a right to request restrictions. The consent to use and disclose your individually identifiable health information provides the ability to request restriction (see attached consent form). We do not, however, have to agree to the restriction. If we do, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternative means and, if the method of communication is reasonable, we must grant the alternate communication request. Again, see the consent form.
• Obtain a paper copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.
• Receive confidential communications of your protected health information.
• Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:

 

• Psychotherapy notes. Such notes are those that are recorded in any medium by a healthcare provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint or family counseling session and are kept separate from the rest of your medical record.
• Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
• Iformation obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

• Protected health information ("PHI") that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C. § 263a, to the extent that providing access to you would be prohibited by law

In other situations, we may deny you access but, if we do, we must provide you with a review of the decision denying access. These "reviewable" grounds for denial include:

• Licensed healthcare professional had determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or another person.
• PHI makes reference to another person (other than a healthcare provider) and a licensed healthcare provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
• The request is made by your personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to you or another person. For such reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review.

If we grant access, we will tell you what, if anything, you have to do to get access. We will reserve the right to charge a reasonable, cost-based fee for making copies.

• Request amendment/correction of your health information. We do not have to grant the request if:

• We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If they amend or correct the record, we will put the corrected record in our records.
• The records are not available to you as discussed immediately above.
• The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those you identify to us that you want to receive the corrected information.

• Obtain an accounting of "non-routine" uses and disclosures - those other than for treatment, payment, and healthcare operations. We do not need to provide an accounting for:

• Disclosures of PHI to you.
• Persons involved in your care or for other notification purposes as provided in 164.510 (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of your location, general condition, or death).
• National security or intelligence purposes under § 164.512(k)(2) (disclosures not requiring consent, authorization, or an opportunity to object).
• To correctional institutions or law enforcement officials under § 164.512 (k)(5) (disclosures not requiring consent, authorization, or an opportunity to object).
• That occurred before April 14, 2003.

We must provide the accounting within 60 days. The accounting must include:

• Date of each disclosure.
• Name and address of the organization or person who received the PHI.
• Brief description of the information disclosed.
• Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of the written request for disclosure.

The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.

• Revoke your consent for authorization to use or disclose health information except to the extent that we have already taken action in reliance on the consent or authorization.

Our Responsibilities Under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to:

• Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
• Provide you with this notice as to our legal duties and privacy practices with respect to individually identifiable health information we collect and maintain about you.

We reserve the right to change our practices and to make the new provisions effective for all individually identifiable health information we maintain. Should we change our information practices, we will mail a revised notice to the address you've supplied us.

• Abide by the terms of this notice
• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to discipline those who breach privacy/ confidentiality or our policies with regard thereto.
• Mitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

Practices within our offices

• When you call us and when we call you, we will verify to whom we are speaking by verifying certain personal information.
• From time to time you may walk past areas in our office where other patients are awaiting consultation or treatment, we ask that you respect the privacy of others.
• When we come to our lobby to bring you in for consultation or treatment, we will call you by name.
• We will leave results and instructions on your answering machine only with your written authorization.
• At checkout, we may discuss with you your next appointment which may be heard by other patients also waiting to checkout.
• From time to time your chart will be transported between our offices, by an ACRM physician, staff person or commercial courier.
• If you send pictures to us of you or your family, we may put them on our family picture boards in the corridors of our offices with your written consent.
• In respect of your right to privacy, our staff will discuss your care with you in a private setting.
• acy/confidentiality.
• When a couple is in treatment, in certain circumstances, reference may be made in one person's medical record about information contained in the other party's medical record.
• If a known third party is involved in your treatment process (e.g. gamete donation, gestational carrier, gamete recipient), we will ask all parties to sign a consent to allow us to share information about the respective parties that we determine, in our sole judgment, is pertinent.

How to Get More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact the Administrative Manager at (770) 928-2276. If you believe your privacy rights have been violated, you can file a complaint with the Administrative Manager at (770) 928-2276 or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. You must submit a completed HIPAA Privacy Incident Report form to the Administrative Manager. The Privacy Compliance Specialist will investigate the complaint and present the complaint to the Chief Financial Officer.

Examples of Disclosures for Treatment, Payment and Health Operations

• We will use your health information for treatment.
  Example: A physician, nurse, medical assistant, mental health professional, clinical social worker, other therapist or counselor, or other member of your healthcare team will record information to diagnose your condition and determine the best course of treatment for you. The primary caregiver will give treatment orders and document what he or she expects other members of the healthcare team to do to treat you. Those other members will then document the actions they took and their observations. In that way, the primary caregiver will know how you are responding to treatment and the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
  We will also provide a subsequent healthcare provider with copies of your records to assist them in treating you once we are no longer treating you.
• We will use your health information for payment.
  Example: We will send a bill to you or to a third-party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received, and supplies used.
• We will use your health information for regular health operations.
  Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

  
  Business associates: We provide some services through contracts with business associates. Examples include anesthesia, mental health services, diagnostic tests, radiology services, insurance benefit verification, and information technology services. When we use these services, we may disclose your health information to the business associate so that they can perform the function(s) we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

  Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

  Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care

  Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
  Marketing/continuity of care: 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.

  Food and Drug Administration ("FDA"): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

  Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

  Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, or charged with reporting health related information in the interest of the public. In that regard, data from your assisted reproductive technology (ART) procedure will also be provided to The Society for Assisted Reproductive Technology (SART) for submission to The Centers for Disease Control and Prevention (CDC). The 1992 Fertility Clinic Success Rate and Certification Act requires that CDC collect data on all ART cycles performed in the United States annually and report success rates using these data. Because sensitive information will be collected on you, CDC applied for and received an "assurance of confidentiality" for this project under the provisions of the Public Health Service Act, Section 308(d). This means that any information that CDC has that identifies you will not be disclosed to anyone else without your consent.

  Correctional institution/Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

  Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.
  

  The Federal Department of Health and Human Services ("HHS"): Under the privacy standards, we must disclose your health information to HHS as necessary for them to determine our compliance with those standards.

  Effective Date: April 14, 2003