THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At CNY Fertility Center, we are committed to treating and using protected health information about you responsibly. This Notice of health information practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.
Understanding Your Health Record/Information: Each time you visit CNY Fertility Center, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights:
Although your health record is the physical property of CNY Fertility Center, the information belongs to you. You have the right to:
Our Responsibilities: CNY Fertility Center is required to:
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you.
We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
For More Information or to Repost a Problem: If you have questions and would like additional information, you may contact the practice’s Privacy officer, Deb Woodhouse at (315)469-8700.
If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer or with the Office for Civil Rights, U.S. Department of Health
and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.
The address for the OCR is listed below:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
We will use your health information for treatment. An example of this is: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine 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 health care team. Members of your health care 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 your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from the hospital.
We will use your health information for payment and Appointment Reminders: An example of this: a bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may use and disclose health information to contact you and to remind you that you have an appointment.
We will use your health information for health care operations: An example of this: 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 case and others like it. We also, may share information with other entities that have a relationship with you (for example, your health insurance company). This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
We may disclose health information to our business associates that perform functions on our behalf or provide services to CNY Fertility Center, if the information is necessary for such functions or services. For Example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than specified in our contract.
Communication with Family:
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. Health professionals, using their best judgment, may disclose to a family member, other relative or close family friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Under certain circumstances, we may use and disclose Health Information to researches 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.
Your name and address will remain on file with the New York State Tissue Bank, and shall not be disclosed to any person or entity, except upon written informed consent, or to authorized employees of New York State Department of Health
(NYSDOH) or as permitted by law.
Date from your ART procedure will also be provided to the Society for Assisted Technology (SART) and the centers for Disease Control and Prevention (CDC). The 1992 Fertility Clinic Success Rate and Certification Act requires that CSC collect data on all assisted reproductive technology cycles performed in the United States annually and report success rates using this data. Because sensitive information will be collected on you, CSC 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 CSC has that identifies you will not be disclosed to anyone else without your consent.
By signing the consent form, the patient and, if applicable, her husband or partner acknowledges that the disposition of blood, semen, egg cells and other specimens utilized in IVF procedures is within the sole discretion of CNY Fertility Center.
As Required by Law:
We will disclose Health Information when required to do so by International, Federal, State or Local law.
To Avert a Serious Threat to Health or Safety:
We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Organ and Tissue Donation:
If you are an organ donor, we may use or release health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation, and transplantation.
Military and Veterans:
If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to appropriate foreign military authority if you are a member of a foreign military.
We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks:
We may disclose Health Information for public health activities. These activities generally include disclosure to prevent or control disease, injury or disability; report births and death; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by authorized by law.
Health Oversight Activities:
We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes:
If you are involved in a lawsuit or dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
We may release Health Information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under very limited circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and 6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.
Coroners, Medical Examiners, and Funeral Directors: We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release health Information to funeral directors as necessary for their duties.
You have the following rights regarding Health Information about you.