Chattanooga 423.899.0500
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Privacy Statement
Fertility Center, LLC
1624 Gunbarrel Road
Chattanooga, TN 37421
423.899.0500
423.899.2411(fax)
10413 Kingston Pike, Suite 201
Knoxville, TN 37922
865.692.3433
865.692.3218 (fax)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003, this Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your protected health information.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. Any healthcare professional authorized to enter information into your medical chart, all departments of the company, all of our employees and staff, and all Fertility Center, LLC satellite locations must abide by the terms of the notice that is currently in effect.
Any questions regarding this notice should be directed to our Privacy Officer who may be contacted at 423.899.0500.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
The following categories contain examples of the types of uses and disclosures of your protected health information that we are permitted to make. PLEASE NOTE: This list is not exhaustive but rather is intended to describe the types of uses and disclosures that may be made by the Fertility Center, LLC.
Treatment – We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians or other personnel who are involved in your medical care. For example, information related to your treatment may be shared with a health care provider, such as your physician, a pharmacist, nurse or other person providing health services to you. This information is necessary for health care providers to determine what treatment you should receive. Health care providers also may record actions taken by them in the course of your treatment and note how you responded to the actions.
Payment – We may use and disclose medical information about you in order to obtain payment for your health care services. For example, a bill may be sent to you or a third party payor, such as Medicare, an insurance company or health plan. The information on the bill may include information that identifies you, your diagnosis, and treatment or supplies used in the course of your treatment. In some instances, we may disclose health information about you to an insurance plan before you receive certain health care products or services to determine whether the insurance plan will pay for the particular product or service. If other treatment providers need medical information about your treatment in order to bill for their services, we may provide it to them.
Health Care Operations – We may use and disclose medical information about you for administrative and operational purposes. Risk management or quality improvement personnel may use health information about you to assess the care and outcomes in your case and others like it. The results will be used internally to continually improve the quality of care for all patients. For example, we may combine medical information about many patients to evaluate the need for new products, services or treatments. We may disclose information to health care professionals, students and other personnel for review and training purposes. We may also combine health information we have with other sources to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy and to allow others to use the information to study health care without learning the identity of the specific patients.
Other uses and disclosures – We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. We may release medical information about you to a friend or family member who is involved in your medical care and we may also give information to someone who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort (such as Red Cross) so that your family can be notified about your condition, status and location. We may disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be limited to someone able to help prevent the threat. We may release medical information about you for workers' compensation or similar programs.
We may disclose medical information about you for public health activities. These activities generally include the following:
► prevent or control disease, injury or disability
► report births and deaths
► report child abuse or neglect
► report reactions to medications or problems with products
► notify people of recalls of products they may be using
► notify a person who may have been exposed to a disease or may be at risk for contracting
or spreading a disease or condition
► notify the appropriate government authority if we believe a patient has been the victim of
abuse, neglect or domestic violence (disclosure will be made only if patient agrees
or if we are required or authorized by law)
We may disclose medical information to a health oversight agency for activities authorized by law. Examples of these oversight activities include:
► audits
► investigations
► inspections
► licensure
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by another party 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 medical information if asked to do so by a law enforcement official in the following circumstances:
► in response to a court order, subpoena, warrant, summons or similar process
► to identify or locate a suspect, fugitive, material witness, or missing person
► about the victim of a crime if, under certain limited circumstances, we are unable to obtain
the person’s agreement
► about a death we believe may be the result of criminal conduct
► about criminal conduct at the facility
► in emergency circumstances to report a crime, the location of the crime or victims, or the
identity or description or location of the person who committed the crime
We may release medical 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 may also release medical information about patients to funeral directors as necessary to carry out their duties.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
Right to Inspect and Copy – You have the right to inspect and copy medical information about you that may be used to make decisions about your care. Typically, this includes medical and billing records. PLEASE NOTE: This does not include psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Fertility Center, LLC, Attention: Health Information Services/Record Request, 1624 Gunbarrel Road, Chattanooga, TN 37421 or 10413 Kingston Pike, Suite 201, Knoxville, TN 37934. We will charge a fee for the costs of copying, mailing and other supplies associated with your request. Additional fees may apply for formats other than a regular hard copy of documents. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request a review of the denial. Another licensed health care professional chosen by the Fertility Center, LLC will review your request and the denial. We will comply with the outcome of this review.
Right to Amend – If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Fertility Center, LLC. A request for an amendment must include a statement supporting a basis for the request and must be made in writing and submitted to; Fertility Center, LLC, Attention: Compliance Officer, 1624 Gunbarrel Road, Chattanooga, TN 37421. In addition, you must provide a reason that supports your request.
We may deny your request to amend information if no reason for the amendment is included in the requestthe information or if the information:
► was not created by us, unless the person or entity that created the information is no
longer available to make the amendment
► is not part of the medical information kept by or for the Fertility Center, LLC
► is not part of the information which you would be permitted to inspect and copy
► is accurate and complete
Right to an Accounting of Disclosures – You have the right to request an ''accounting of disclosures'' of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this notice. This excludes disclosures we have made to you of your own protected health information; disclosures for a facility directory or to persons involved in your care; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials; or disclosures that occurred prior to April 14, 2003. To request an accounting of disclosures, you must submit your request in writing to the Fertility Center, LLC, Attention: Compliance Officer, 1624 Gunbarrel Road, Chattanooga, TN 37421. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Receive Confidential Communications – You have the right to request that communications of your protected health information be received by alternative means (for example, electronically, by phone, postal mail) or at an alternative location. For example, you may prefer that your statements be received at a location other than your home address. Requests may not interfere with our ability to collect payment for services, or to contact you by some method. Requests will be reviewed in a timely manner, and all reasonable requests will be accepted. You will receive notification of acceptance and the effective date of the request. A request for alternative communication methods must be in writing to the Fertility Center, LLC, Attention: Compliance Officer, 1624 Gunbarrel Road, Chattanooga, TN 37421.
Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. Your request must state the specific restriction requested and to whom you want the restriction to apply. PLEASE NOTE: We are not required to agree to your request. If we do agree with the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. To request restrictions, your request must be in writing to the Fertility Center, LLC, Attention: Compliance Officer, 1624 Gunbarrel Road, Chattanooga, TN 37421. Your request, must state (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the restrictions to apply.
Right to a Paper Copy of This Notice – You have the right to request a paper copy of this notice at any time, even if you have agreed to receive this notice electronically. To obtain a paper copy of this notice, visit any Fertility Center, LLC, location or send a request in writing to the Fertility Center, LLC, Attention: Health Information Services, 1624 Gunbarrel Road, Chattanooga, TN 37421, or call 423.899.0500.
CHANGES TO THIS NOTICE
We reserve the right to amend this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the most current notice in all of our facilities as well as on our website.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Fertility Center, LLC, and/or with the Secretary of the Department of Health and Human Services. To file a complaint with Fertility Center, LLC, send a written letter of complaint to the Fertility Center, LLC, Attention: Compliance Officer, 1624 Gunbarrel Road, Chattanooga, TN 37421. PLEASE NOTE: You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, 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. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.