Effective April
14, 2003
This notice describes how medical information about
you may be used and disclosed and how you can obtain
access to this information. Please review it carefully.
If you have any questions about this notice, please
contact us.
Our Pledge Regarding
Medical Information
We are required
by law to:
make sure your health information is kept private;
give you this notice of our legal duties and privacy
practices; and
follow the terms of this notice.
We understand
that your health information is personal.
We create a
record of the care and services you receive. We need
this record to provide you with quality care and to
comply with certain legal requirements.
We are committed
to protecting this information.
This Notice Will
Tell You About:
the ways in which we may use and disclose your health
information;
your rights; and your obligations regarding the use
and disclosure of health information.
How We May Use And
Disclose Your Health Information
We may use or share your health information in certain
ways. We will explain how and when we may use or share
your health information. We are not able to list each
specific way in which we may use or share your health
information, but each situation will fall into one
of the basic types of situations outlined below:
FOR TREATMENT: In order to effectively treat you,
it is important that we be able to use or share your
information. We may share your information with doctors,
nurses, medical students, or other personnel who are
involved in your care.
For your treatment purposes, we may share your information
with healthcare providers outside of Ohio Reproductive
Medicine. For example, we may need to include records
when updating your referring physician on your progress.
Also, we may need to share your information with an
outside medical professional in order to schedule
you for a surgery or procedure.
FOR PAYMENT: We may use or share your health information
to ensure we are paid for the cost of your care. We
may share your information with another provider so
he or she may be paid for services as well. We may
bill and share information with other providers, an
insurance company, you, or a third party. For example,
we may need to give your health plan provider information
about your diagnosis and treatment so they will pay
us or reimburse you for the care we provided. We may
also inform your health plan provider about a treatment
you are going to receive so as to obtain prior approval
or to determine whether your plan will cover such
treatment. We may also share your health information
with another provider who has participated in your
care in order to facilitate payment.
FOR HEALTHCARE EVALUATION: We may use and share your
health information for healthcare evaluation purposes.
These uses and disclosures are necessary to run our
facility and ensure that all our patients receive
quality care.
For example, we may use medical information to review
our treatment and services and to evaluate the performance
of our staff in caring for you. We may also combine
medical information about many of our patients to
decide what additional services we should offer, what
services are not needed, and whether certain new treatments
are effective.
We may also disclose information to doctors, nurses,
technicians, student trainees, and other healthcare
facility personnel for review and learning purposes.
We may combine the medical information we have with
medical information from other facilities to compare
how we are doing and to see where we can make improvements
in the care and services we offer. When we share medical
information with other facilities for this type of
comparison, we remove all information that identifies
you so others may use it to study health care and
healthcare delivery without knowing who you are.
APPOINTMENT REMINDERS: We may use and disclose medical
information to contact you as a reminder that you
have an appointment. If you do not wish to receive
appointment reminders, or you wish to be contacted
at a certain telephone number, be sure to tell us.
HEALTH-RELATED BENEFITS AND SERVICES: We may use and
disclose medical Information to inform you of treatment
options, health-related benefits, or services that
may be of interest to you.
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR
CARE: We may release medical information about you
to a family member or other designated person who
is involved in your medical care. We may also give
information to someone who helps pay for your care.
For example, we may need to tell the person who comes
to pick you up after your appointment what he or she
needs to do to help you once you get home. In the
event of an emergency, we may need to use or share
information about you in order to inform your family
or persons responsible for your care where you are
and what your condition is.
SPECIAL SITUATIONS: Additional uses and disclosures
for which authorization or opportunity to agree or
object is not required by the Health Insurance Portability
and Accountability Act (HIPAA).
RESEARCH: You may have the opportunity to be a part
of Ohio Reproductive Medicine’s research efforts.
Under certain circumstances, we may use and disclose
medical information about you for research purposes,
or we may contact you about research projects for
which you may qualify.
All research projects are subject to a special approval
process before we use or disclose medical Information.
We also may disclose medical information about you
to people who are preparing to conduct a research
project. They may be looking for patients with specific
needs or for certain information. In either case,
the medical information they review will be kept confidential.
AS REQUIRED BY LAW: We will disclose medical information
about you when required to do so by federal, state,
or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We
may use and disclose medical information about you
when necessary to prevent a serious threat to your
health and safety or to the health and safety of the
public or another person.
VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: We
may disclose certain health information to government
agencies that are authorized by law to receive reports
of abuse, neglect, or domestic violence if we believe
you have been a victim of such events.
HEALTH OVERSIGHT ACTIVITIES: We may disclose medical
information to a health oversight agency for activities
that are authorized by law. These oversight activities
include, for example, audits, investigations, inspections,
and licensure.
JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may disclose
your health information in the course of an administrative
or judicial proceeding, such as in response to a court
order.
LAW ENFORCEMENT: We may release medical information
about you to law enforcement officials if required
to do so by law.
Uses Of Medical Information
That Require Authorization
In all other situations (situations that are not treatment-related,
payment-related, healthcare evaluation-related, or
special situations, as mentioned above), we may only
share information with your specific written authorization.
You may revoke that authorization, in writing, at
any time. If you revoke your permission, we will no
longer use or disclose medical information about you
for the reasons covered by your written authorization,
except to the extent that we already have used or
disclosed such information.
Your Rights Regarding
Medical Information About You
Although the physical form of your medical information
or designated record set is our business record and
is the property of Ohio Reproductive Medicine, the
information contained therein is your information,
and you have certain rights regarding that information.
You have the following rights regarding medical information
we maintain about you:
Right To Review And Copy: You have the right to inspect
and obtain a copy of medical information that may
be used to make decisions about your care.
Usually, this information includes medical and billing
records, but does not include records forwarded to
us from another facility or physician or certain lab
test results subject to the Clinical Laboratories
Improvement Act of 1988. You must submit your request
for your medical information in writing. If you request
a copy of this information, we may charge a fee for
the costs of copying, mailing, or other supplies associated
with your request.
Right To Appeal A Denial Of Access To Medical Information:
You have a right to access your medical information.
There are, however, some limitations on that right.
If for clear treatment reasons your physician has
determined that access to your health information
is likely to have an adverse effect on you, the physician
shall provide the record to a practitioner who has
been designated by you to assist you in your review
of the information.
Right To Amend: If you feel that medical information
we have about you is incorrect or incomplete, you
may ask us to amend that information. You have the
right to request an amendment for as long as the information
is maintained. We may deny your request if you ask
us to amend information that:
is not part of the information you would be permitted
to inspect and copy; or
we believe is accurate or complete.
Submit your request for amendment to your physician.
Your request must be made in writing and include a
reason that supports your request.
Right To Accounting Of Disclosures: You have the right
to request an accounting of disclosures. This is a
list of health/medical information disclosures about
you that we have made to others in certain “special
situations” as listed above.
These disclosures are not related to treatment, payment,
or healthcare evaluation and occur when we are not
required to obtain your authorization before we share
your information with others.
You must submit your request for accounting disclosure
in writing. Your request must tell us the calendar
dates you want to see. The time period cannot include
more than six years of information and cannot begin
prior to April 14, 2003. There will be no charge for
the first list you request within a 12-month period.
We may, however, charge you for the costs of providing
any additional lists. In that event, we will notify
you of the cost involved. You may choose to withdraw
or modify your request at that time, before any costs
are incurred.
Right To Request Restrictions: You have the right
to request a restriction or limitation on the health
information we use or disclose about you for treatment,
payment, or healthcare evaluation purposes. We are
not, however, required to agree to your request. If
we do agree, we will comply with your request unless
the information is needed to provide you with emergency
treatment. You must make your request for restriction
in writing. In your request, you must tell us what
information you want to limit and whether you want
to limit our use, disclosure, or both.
Right To Request Confidential Communications: You
have the right to request that we communicate with
you about medical matters in a certain way or at a
certain location. For example, you can ask that we
only contact you at home. You must make your request
for confidential communication made known to us. We
will not ask you the reason for your request and we
will accommodate all reasonable requests.
Right to a paper copy of this notice: You have the
right to a paper copy of this notice. You may ask
for a copy of this notice at any time. Click here
to print a copy of this entire notice.
Changes To This Notice
We reserve the right to change this notice. We reserve
the right to make the revised or changed notice effective
for medical information we already have about you
as well as for any information we receive in the future.
Current copies of this notice will be available in
our office at the front desk. The current notice will
also be posted at our website: www.ohiorepromed.com.
The effective date of the notice will be posted on
the first page.
Complaints
Ohio Reproductive Medicine is dedicated to ensuring
your privacy rights, consistent with the Health Insurance
Portability and Accountability Act (HIPAA).
If you believe your privacy rights have been violated,
you may file a complaint with our office. All complaints
must be made in writing and be mailed to us. You will
not be penalized for filing a complaint.
