LIFESOURCE FERTILITY CENTER
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY
If you have any questions about this Notice, please contact our Privacy Officer:
We understand that medical information about you and your health is personal and we are committed to protecting that information. We create a record of the care and services you receive at LifeSource Fertility Center in order to provide you with quality care and to comply with certain legal requirements.
As required by federal regulations, the Notice of Privacy Practices summaries how we may use and disclose medical information about you, including demographic information that may identify you and your related health care services to carry out your treatment, obtain payment for our services, to perform the daily health care operations of this practice and for other purposes that are permitted or required by law. This notice also describes your rights to access and control your medical information.
We are required to abide by the terms of this Notice of Privacy Practices.
- Written Acknowledgement
You will be asked to sign a written statement acknowledging that you have received a copy of this notice. The acknowledgement only serves to create a record that you have received a copy of the notice.
- Changes to this Notice
We may change the terms of our Notice at any time. The new Notice will be effective for all medical information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.
- How We May Use and Disclose Medical Information about You
The following categories describe the different ways we may use and disclose your medical information. Other uses and disclosures of your medical information that are not listed or described below will be made only with your written authorization. You may revoke this authorization at any time in writing but it will not apply to any actions we have already taken.
- For your treatment: Your medical information may be used and disclosed by us for providing medical treatment to you or for another physician providing medical treatment to you. This information may be faxed or mailed to the other physician.
- To obtain payment for our services: Your medical information may be used and disclosed by us to obtain payment for your health care bills or to assist another health care provider in obtaining payment for their health care bills.
- For our health care operations: Your medical information may be used to see where or how we can improve our care.
- For the health care operations of other health care providers: We may also use your medical information to assist another health care provider treating you with its quality improvement activities.
For appointment reminders: We may use or disclose your medical information to contact you to remind you of your appointment by mail or telephone.
- To provide you with treatment alternatives: We may use or disclose your medical information to provide you with information about treatment alternatives or other health related services that may be of interest to you.
- To our business associates: We will share your medical information with third party "business associates" that perform various activities (e.g., transcription services) for the practice. Your medical information will be disclosed to this transcription service but a written agreement between our office and the transcription service will prohibit them from using your medical information in any way other than what we allow.
- Others Involved in Your Health Care: Unless you object, we may disclose to a member or your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person’s involvement in your health care.
- As required by law: We may use or disclose your medical information to the extent that law requires the use or disclosure.
- For public health activities: We may disclose your medical information to a public health authority that is permitted by law to collect of receive the information.
- As required by the Food and Drug Administration: We may disclose your medical information to a person or company required by the Food and Drug Administration to report adverse events, etc.
- For communicable disease exposure: We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or at risk of contracting or spreading the disease or condition.
- To your employer: We may disclose your medical information concerning a work related injury or illness to your employer if you are covered under your employer’s policy in accordance with the law.
- For abuse or neglect: We may disclose your medical information to a public health authority that is authorized by law to receive reports of child or adult abuse or neglect as may be required or permitted by Virginia and/or federal law.
- For health oversight: We may disclose your medical information to a health oversight agency for activities authorized by law.
- In legal proceedings: We may disclose your medical information in the course of any judicial or administrative proceeding and in certain conditions in response to a subpoena or other lawful request.
- For informational purposes: We may use any picture and/or card you send of yourself and your children in our photo albums in the waiting room, unless requested not to do so.
- For law enforcement: We may also disclose your medical information, so long as all legal requirements are met, for law enforcement purposes.
- To coroners, funeral directors and for organ donation: We may disclose your medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.
- For research: We may disclose your medical information to researchers when their research has been established as required by federal and state law.
- Due to criminal activity: Consistent with applicable federal and state laws, we may disclose your medical information if we believe the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety or a person or the public.
- For military activity and national security: When the appropriate conditions apply, we may use or disclose medical information of individuals who are Armed Forces personnel. We may also disclose your medical information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
- For workers’ compensation: We may disclose your medical information as authorized to comply with workers’ compensation laws and other similar legally established programs.
- Regarding inmates: We may use or disclose your medical information if you are an inmate or a correctional facility and your physician creased or received your medical information in the course of providing care to you.
- For required uses and disclosures: Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of HIPAA and its regulations.
- For educational purpose: We may use your name and address to send notification of educational seminars, etc. in which Dr. Gianfortoni will be participating.
- Your Rights
The following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights:
You have the right to inspect and copy your medical information. Under federal law, you may not inspect or copy the following records: psychotherapy notes, information compiled related to a civil, criminal or administrative action, or medical information that is subject to law that prohibits access to medical information in certain circumstances. We may deny your request to inspect your records. Please contact our Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your medical information. This means you may ask us not to use or disclose any part of your medical information for the purposes of treatment, payment or health care operations. You may also request that any part of your medical information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply.
You have the right to request that we accommodate you in communicating confidential medical information. We will accommodate reasonable requests, but we may ask you how payment will be handled or other information necessary to honor your request. This request must be in writing to our Privacy Officer.
You have the right to ask us to amend your medical information.
You have the right to receive an accounting of certain disclosures we have made, if any, of your medical information. This is for disclosures for purposes other than treatment, payment or health care operations. You may only ask for disclosures after April 14, 2003.
You have the right to obtain a paper copy of this notice from us.
You may complain to us if you believe your privacy rights have been violated by us. To file a complaint, please contact our Privacy Officer.
- Privacy Contact
If you have any questions about the Notice or require additional information, please contact our Privacy Officer at (804) 673-2273 or at 7603 Forest Avenue, #204, Richmond, VA 23229 during normal business hours.
- Effective Date
This notice becomes effective April 14, 2003.