THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Notice Describes:
- How medical information may be used and disclosed
- Your rights with respect to your medical information
- How to exercise your right to get copies of your records at limited cost or, in some cases, free
of charge. - How to file a complaint concerning a violation of the privacy, or security of your medical
information, or of your rights concerning your information, including your right to inspect or get
copies of your records under HIPAA. - You have a right to get a copy of this notice (in paper or electronic form) and to discuss it with
our Compliance Officer, Karen Guccione at 732-807-1613 EXT. 105 or via email at
[email protected] if you have any questions.
Uses and Disclosures of Private Health Information (PHI)
Protected health information is information about you, including demographic information,
which may identify you and that relates to your past, present or future physical or mental health
or condition and related health care services.
Your protected health information may be used and disclosed by Conceive NJ, our clinical staff
and other third parties involved in your care and treatment for the purpose of providing health
care services to you, to pay your health care bills, to support the operation of Conceive NJ, and
any other use required by law.
Treatment: Conceive NJ will use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This includes the coordination
or management of your health care with a third party. For example, we may disclose Health
Information to doctors, nurses, technicians, or other personnel, including people outside our
office, involved in your medical care and need the information to provide you with medical care.
Payment: Conceive NJ may use and disclose Health Information so that we or others may bill
and receive payment from you, an insurance company or a third party for the treatment and
services you received. For example, we may give your health plan information about you so that
they will pay for your treatment.
Healthcare Operations: Conceive NJ may use and disclose Health Information for health care
operations purposes. These uses and disclosures are necessary to make sure that all of our
patients receive quality care and to operate and manage our office. For example, we may use and
disclose information to make sure the obstetrical or gynecological care you receive is of the
highest quality. We also may share information with other entities that have a relationship with
you such as your health care plan.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and
Services: We may use and disclose Health Information to contact you to remind you that you
have an appointment with us. We also may use and disclose Health Information to tell you about
treatment alternatives or health-related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: When appropriate, we may
share Health Information with a person who is involved in your medical care or payment for
your care, such as your family or a close friend. We also may notify your family about your
location or general condition or disclose such information to an entity assisting in a disaster relief
effort.
Research: Under certain circumstances, we may use and disclose Health Information for
research. For example, a research project may involve comparing the health of patients who
received one treatment to those who received another, for the same condition. Before we use or
disclose Health Information for research, the project will go through a special approval process.
Even without special approval, we may permit researchers to look at records to help them
identify patients who may be included in their research project or for other similar purposes, as
long as they do not remove or take a copy of any Health Information.
SPECIAL SITUATIONS WHERE PHI MAY BE DISCLOSED:
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.
Business Associates: We may disclose Health Information to our business associates that
perform functions on our behalf or provide us with services 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 as specified in our
business associate agreement.
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 the appropriate foreign military authority if you are a member of a foreign
military.
Workers’ Compensation: 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 disclosures to 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; a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease or condition; and 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 or
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.
Data Breach Notification Purposes: We may use or disclose your Protected Health Information
to provide legally required notices of unauthorized access to or disclosure of your health
information.
Lawsuits and Disputes: If you are involved in a lawsuit or a 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.
Law Enforcement: 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 certain 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.
Patient Rights
You have the following rights regarding your health information we have on file:
Right to Inspect and Copy: You have a right to inspect and copy Health Information that may
be used to make decisions about your care or payment for your care. This includes medical and
billing records, other than psychotherapy notes. To inspect and copy this Health Information, you
must make your request, in writing, to Administrative Staff. We have up to 30 days to make your
Protected Health Information available to you and we may charge you a reasonable fee for the
costs of copying, mailing or other supplies associated with your request. We may not charge you
a fee if you need the information for a claim for benefits under the Social Security Act or any
other state of federal needs-based benefit program. We may deny your request in certain limited
circumstances. If we do deny your request, you have the right to have the denial reviewed by a
licensed healthcare professional who was not directly involved in the denial of your request, and
we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records: If your Protected Health
Information is maintained in an electronic format (known as an electronic medical record or an
electronic health record), you have the right to request that an electronic copy of your record be
given to you or transmitted to another individual or entity. We will make every effort to provide
access to your Protected Health Information in the form or format you request if it is readily
reproducible in such form or format. If the Protected Health Information is not readily
reproducible in the form or format you request your record will be provided in either our
standard electronic format or if you do not want this form or format, a readable hard copy form.
We may charge you a reasonable, cost-based fee for the labor associated with transmitting the
electronic medical record.
Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your
unsecured Protected Health Information.
Right to Amend: If you feel the Health Information we have 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 our office. To request an amendment, you must make your
request, in writing, to our Compliance Officer.
Right to an Accounting of Disclosures: You have the right to request a list of certain
disclosures we made of Health Information for purposes other than treatment, payment, and
health care operations or for which you provided written authorization. To request an accounting
of disclosures, you must make your request, in writing, to Compliance Officer.
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 by e-mail or at work. To request confidential
communications, you must make your request, in writing, to Compliance Officer. Your request
must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You
may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy
of this notice, please contact our Compliance Officer.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information
we already have as well as any information we receive in the future. We will post a copy of our
current notice at our office. The notice will contain the effective date on the first page, in the top
right-hand corner.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or
with the Secretary of the Department of Health and Human Services. To file a complaint with
our office, contact our Compliance Officer. All complaints must be made in writing. You will
not be penalized for filing a complaint.