ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

The Institute for Reproductive Medicine and Science at Saint Barnabas, PA

Effective Date: June 1, 2013
Version 1

SUMMARY

WHAT IS THIS NOTICE FOR? This Notice of Privacy Practices (Notice) describes how The Institute for Reproductive Medicine and Science at Saint Barnabas, PA (We or Us) may use and disclose your medical information that we maintain and how you can get access to this information.

WHO ARE WE? The Institute for Reproductive Medicine and Science at Saint Barnabas, PA is a privately owned Reproductive Endocrinology and Infertility medical practice which consists of all employed doctors, nurses, employees and other healthcare professionals. This Notice applies to these individuals as well as all services that are provided to you at our facility/any of our facilities, including but not limited to: 94 Old Short Hills Rd, Livingston NJ; 101 Old Short Hills Rd, West Orange NJ; 609 Washington St., Hoboken NJ; 100 Walnut St., Clark NJ; 375 US Highway 130 East Windsor NJ.

WHY DO YOU NEED THIS NOTICE? The Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act, places certain obligations upon us with regard to how we may use and disclose your personal health information (PHI). Your PHI includes medical information about you such as your medical record and the care and services you have received. We are committed to maintaining the privacy of your PHI. When we need to use or disclose it, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

WHEN CAN WE USE/DISCLOSE YOUR PHI? There are certain uses and disclosures of your PHI that we may undertake without your written or other authorization. These uses and disclosures may be for purposes such as to provide you with treatment, obtain payment for services we have provided, and other health care operations (such as administration, quality improvement, cost studies and other activities designed to improve the care we provide to all our patients). Some other examples include: PHI made known to your relatives, close friends, or caregivers, public health activities and officials, reporting of abuse or neglect as may be required by law, health oversight activities, judicial and administrative proceedings, law enforcement officials, workers’ compensation, and other individuals and activities as set forth in this Notice. Individuals who may have access to your information without your written or other authorization may include doctors, nurses, health care students, and other hospital staff.

WE MUST OBTAIN YOUR WRITTEN AUTHORIZATION FOR ANY USE OR DISCLOSURE NOT SET FORTH IN THIS NOTICE. You may revoke this authorization AT ANY TIME. In addition to obtaining your written authorization for uses or disclosures not described in this Notice, we generally will also need to seek your written authorization or approval prior to disclosing the following information:

  • HIV/AIDS related information
  • Sexually transmitted disease information
  • Tuberculosis
  • Psychotherapy notes
  • Mental health information
  • Drug & alcohol information
  • Genetic information
  • Any information where you, if a minor, sought emancipated treatment (e.g., care related to your pregnancy or child, sexually transmitted diseases, etc)

We will also seek your written authorization for any “marketing” activities we may conduct or where we would receive money for providing a third party with your PHI.

WHAT RIGHTS DO YOU HAVE FOR YOUR PHI? You have the right to ask us to limit certain uses and disclosures of your PHI. We will consider ALL requests but may not be required to agree to your requested limitations. You also have the right to inspect and receive copies of your PHI, the right to request a change or amendment be made to your PHI, the right to an accounting (a list) of certain disclosures of your PHI, and the right to revoke any authorization you may have made to the extent we have not yet relied upon it. You also have the right to receive a paper copy of this Notice at any time.

CAN WE CHANGE THIS NOTICE? We may change this Notice at any time. The revised Notice will apply to all PHI that we maintain. However, if we do change this Notice, we will only make changes to the extent permitted by law. We will also make the revised Notice available to you by posting it in a place where all individuals seeking services from us will be able to read the Notice as well as on our website at http://sbivf.com. You may obtain the new Notice in hard copy as well from our Privacy Office.

ADDITIONAL INFORMATION/COMPLAINTS. You may contact our Privacy Office if you wish any additional information or have questions concerning this Notice or your PHI. If you feel that your privacy rights have been violated, you may also contact our Privacy Office OR file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. We will NOT retaliate against you if you file a complaint with us or the Office of Civil Rights.

THE ABOVE IS ONLY A SUMMARY OF THE RIGHTS AND OBLIGATIONS WITHIN THIS NOTICE. PLEASE READ CAREFULLY THE ENTIRE NOTICE THAT FOLLOWS.

WE WELCOME ANY QUESTIONS YOU MAY HAVE.

Patient Name:_________________________________________
Date of Birth
:_____________________

  1. I acknowledge receipt of the Notice of Privacy Practices for The Institute for Reproductive Medicine & Science, PA.
  2. I understand that highly sensitive protected health information will be sent by fax to my primary doctor, ob/gyn and other consulting doctors including results of genetic testing, HIV or sexually transmitted disease testing or information from federally funded drug or alcohol treatment programs.

Signature:_______________________________________________________

NOTICE OF PRIVACY PRACTICES

The Institute for Reproductive Medicine and Science at Saint Barnabas, PA

Effective: June 1, 2013
Version 1

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.

I. WHO WE ARE

This Notice describes the privacy practices of The Institute for Reproductive Medicine and Science at Saint Barnabas, PA (We or Us), and our employed doctors, nurses, employees and other personnel. This Notice applies to all services that are provided to you at our 94 Old Short Hills Rd, Livingston NJ; 101 Old Short Hills Rd, West Orange NJ; 609 Washington St., Hoboken NJ; 100 Walnut St., Clark NJ; and/ or 375 US Highway 130 East Windsor NJ.

II. WHY YOU NEED THIS NOTICE

We are committed to maintaining the privacy of your protected health information (PHI). Your PHI includes medical information about you such as your medical record and the care and services that you have received from us. We need this information to provide you with the appropriate level of care and also to comply with certain legal obligations we may have. We are required by law to provide you with this Notice of our legal duties and privacy practices with respect to your PHI that we maintain.

The Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act, places certain obligations upon us with regard to your PHI and requires that we keep private and confidential any medical information that identifies you. We take this obligation and your privacy seriously and when we need to use or disclose your PHI, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

III. USES AND DISCLOSURES OF YOUR PHI THAT DO NOT REQUIRE YOUR AUTHORIZATION

We are permitted by law to use and disclose your PHI without your written or other form of authorization under certain circumstances as described below. This means that we do not have to ask you before we use or disclose your PHI for purposes such as to provide you with treatment, seek payment for our services, or for health care operations. We may also use or disclose your PHI without asking you for other activities or to state and/or federal officials.

Treatment, Payment and Health Care Operations.

  • Treatment - We may use and disclose your PHI in order to provide you with medical treatment or services. Your PHI may be used or disclosed to our doctors, nurses, employees and other personnel who may be involved in your care. Your PHI may also be disclosed to individuals outside of our facility, such as family members, friends or other caregivers, clergy, nursing homes and other health care providers who may be involved in your care.
  • Payment – We may use and disclose your PHI in order for our doctors and other health care professionals to obtain payment for the medical treatment or services they provide you with. This means that we may provide your health plan or HMO with information regarding treatment you received from us, such as X-Rays or examinations, so that we may properly be paid for such services. We may also contact your health plan or HMO regarding future treatment or services you may be provided with in order to obtain approval or to find out whether your health plan or HMO will pay for the treatment or services.
  • Health Care Operations – We may use and disclose your PHI for our internal health care operations, such as administration, planning, quality improvement, and other activities that help us provide you with quality care. For example, your PHI may be used to help us evaluate our doctors, nurses and employees, or to help us provide them with education and training. Your PHI may also be disclosed to and used by our administrative staff to help us coordinate your care and respond to any concerns you may have.

Other Healthcare Providers. We may disclose your PHI to other health care professionals where it may be required by them to treat you, to obtain payment for the services they provided you with or their own health care operations.

Disclosures to Relatives, Close Friends, Caregivers. We may disclose your PHI to family members and relatives, close friends, caregivers or other individuals that you may identify so long as we:

  • Obtain your agreement;
  • Provide you with the opportunity to object to the disclosure and you do not object; or
  • We reasonably infer that you would not object to the disclosure.

  • If you are not present or, due to your incapacity or an emergency, you are unable to agree or object to a use or disclosure, we may exercise our professional judgment in order to determine whether such use or disclosure would be in your best interests. Where we would disclose information to a family member, other relatives, or a close friend, we would disclose only that information we believe is directly relevant to his or her involvement with your care or payment related to your care. We will also disclose your PHI in order to notify or assist with notifying such persons of your location, general condition or death. You may at any time request that we do NOT disclose your PHI to any of these individuals.

    Public Health Activities. We may disclose your PHI for certain public health activities as required by law, including:

    • to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability;
    • to report certain immunization information where required by law, such as to the state immunization registry or to your child’s school;
    • to report births and deaths;
    • to report child abuse to public health authorities or other government authorities authorized by law to receive such reports;
    • to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration, such as reactions to medications;
    • to notify you and other patients of any product or medication recalls that may affect you;
    • to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and
    • to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

    Health Oversight Activities. We may disclose your PHI to a health oversight agency such as Medicaid or Medicare that oversees health care systems and delivery, to assist with audits or investigations designed for ensuring compliance with such government health care programs.

    Victims of Abuse, Neglect, Domestic Violence. Where we have reason to believe that you are or may be a victim of abuse, neglect or domestic violence, we may disclose your PHI to the proper governmental authority, including social or protective service agencies, who are authorized by law to receive such reports.

    Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a court order, subpoena or other lawful process in the course of a judicial or administrative proceeding. For example, we may disclose your PHI in the course of a lawsuit you have initiated against another for compensation or damage for personal injuries you received to that person or his insurance carrier.

    Law Enforcement Officials. We may disclose your PHI to police or other law enforcement officials as may be required or permitted by law or pursuant to a court order, subpoena or other lawful process. For example, we may disclose your PHI to police in order to identify a suspect, fugitive, material witness or missing person. We may also disclose your PHI to police where it may concern a death we believe is a result of criminal conduct or due to criminal conduct within our premises. We may also disclose your PHI where it would be necessary in an emergency to report a crime, identify a victim of a crime, or identify or locate the person who may have committed a crime.

    Decedents. We may disclose your health information to medical coroners for purposes of identifying or determining cause of death or to funeral directors in order for them to carry out their duties as permitted or required by law.

    Workers Compensation. We may use or disclose your PHI to the extent necessary to comply with state law for workers’ compensation or other similar programs, for example, regarding a work-related injury you received.

    Research. Although generally we will ask for your written authorization for any use or disclosure of your PHI for research purposes, we may use or disclose your PHI under certain circumstances without your written authorization where our research committee has waived the authorization requirement.

    Health or Safety. We may use or disclose your PHI where necessary to prevent or lessen threat of imminent, serious physical violence against you or another identifiable individual, or a threat to the general public.

    Military and Veterans. For members of the armed forces and veterans, we may disclose your PHI as may be required by military command authorities. If you are a foreign military personnel member, your PHI may also be released to appropriate foreign military authority.

    Specialized Government Functions. We may disclose your PHI to governmental units with special functions under certain circumstances. For example, your PHI may be disclosed to any of the U.S. Armed Forces or the U.S. Department of State.

    National Security and Intelligence Activities. We may disclose your PHI to authorized federal officials for purpose of intelligence, counter-intelligence and other national security activities that may be authorized by law.

    Protective Services for the President and Others. We may disclose your PHI to authorized federal officials for purposes of providing protection to the President of the United States, other authorized persons or foreign heads of state or for purposes of conducting special investigations.

    Inmates. If you are an inmate in a correctional institution or otherwise in the custody of law enforcement, we may disclose your PHI about you to the correctional institution or law enforcement official(s) where necessary:

    • For the institution to provide health care;
    • To protect your health and safety or the health and safety of others; or
    • For the safety and security of the correctional institution.

    Organ and Tissue Procurement. Where you are an organ donor, we may disclose your PHI to organizations that facilitate or procure organs, tissue or eye donations or transplantation.

    As Required by Law. We may use or disclose your PHI in any other circumstances other than those listed above where we would be required by state or federal law or regulation to do so.

    IV. USES AND DISCLOSURES OF YOUR PHI THAT REQUIRE YOUR WRITTEN AUTHORIZATION

    In general, we will need your specific written authorization on our HIPAA Authorization Form to use or disclose your PHI for any purpose other than those listed above in Section III. For example, we would need your written authorization to disclose psychotherapy notes, or need you to indicate on the HIPAA Authorization Form that we may send you marketing materials.

    We will seek your specific written authorization for at least the following information unless the use or disclosure would be otherwise permitted or required by law as described above:

    HIV/AIDS information. In most cases, we will NOT release any of your HIV/AIDS related information unless your authorization expressly states that we may do so. There are certain purposes, however, for which we may be permitted to release your HIV/AIDS information without obtaining your express authorization. For example, we may release information regarding HIV/AIDS to your insurance company or HMO for purposes of receiving payment for services we have provided you with. Other instances where we may use or disclose HIV/AIDS information without your express authorization include, but are not limited to:

    • For diagnosis and treatment;
    • For medical education;
    • For disease prevention and control, when permitted by the New Jersey Department of Health;
    • To comply with certain court orders; and
    • When otherwise required by law, to the New Jersey Department of Health, or another entity.

    Sexually transmitted disease information. In certain cases, we must obtain your specific authorization prior to disclosing any information that would identify you as having or being suspected of having a sexually transmitted disease. We may use and disclose information related to sexually transmitted diseases without obtaining your authorization only where permitted by law, including to the New Jersey Department of Health and Senior Services, to your physician or a health authority, or to a prosecuting officer or court if you are being prosecuted under New Jersey law. Where necessary, your physician or a health authority may further disclose such information to protect your health and welfare, or the health and welfare of your family or the public.

    Tuberculosis Information. We must obtain your specific written authorization prior to disclosing any information that would identify you as having or being suspected of having tuberculosis (TB). We may use and disclose TB information where authorized by law, such as for research purposes, to the New Jersey Department of Health, or otherwise authorized by court order.

    Psychotherapy notes. We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law.

    Drug and alcohol information. We must obtain your specific written authorization prior to disclosing information related to drug and alcohol treatment or rehabilitation under certain circumstances such as where you received drug or alcohol treatment at a federally funded treatment facility or program.

    Genetic information. We must obtain your specific written authorization prior to obtaining or retaining your genetic information, or using or disclosing it for treatment, payment or health care operations purposes. We may use or disclose your genetic information without your written authorization only where it would be permitted by law, such as for paternity tests for court proceedings, newborn screening requirements, identifying a body or otherwise authorized by a court order.

    Information related to emancipated treatment of a Minor. If you are a minor who has sought emancipated treatment from us, such as treatment related to your pregnancy or treatment of your child, or a sexually transmitted disease (STD, we must obtain your specific written authorization prior to disclosing any of this information to another person, including your parent or guardian, unless otherwise permitted or required by law.

    Marketing activities. We must obtain your specific written authorization in order to use any of your non “identified” PHI to mail or email you marketing materials. However, we may provide you with marketing materials face-to-face without obtaining authorization, in addition to communicating with you about services or products that relate to your treatment, case management, or care coordination, alternative treatments, therapies, providers or care settings. If you do provide us with your written authorization to send you marketing materials, you have a right to revoke your authorization and may do so at any time for future marketing communications. If you wish to revoke your authorization, please contact the Privacy Office at 973-322-2207 or in writing at 94 Old Short Hills Rd., EW Suite 403, Livingston, NJ 07039.

    Activities where we receive money for exchanging PHI. For certain activities in which we would receive money (remuneration) directly or indirectly from a third party in exchange for your PHI, we must obtain your specific written authorization prior to doing so. However, we would not require your authorization for activities such as for treatment, public health or research purposes. You have a right to revoke your authorization at any time. If you wish to revoke your authorization, please contact the Privacy Office at 973-322-2207 or in writing at 94 Old Short Hills Rd., EW Suite 403, Livingston, NJ 07039.

    V. YOUR RIGHTS REGARDING YOUR PHI

    Right to Inspect/Copy PHI. You have the right to inspect and request copies of your PHI that we maintain. For PHI that we maintain in any electronic designated record set, you may request a copy of such PHI in a reasonable electronic format. If readily producible. However, under limited circumstances, you may be denied access to a portion of your records. For example, if your doctor believes that certain information contained within your medical record could be harmful to you, we would not release that information to you. Please contact Medical Records / Pamela Schwarz if you would like to inspect or request copies of your PHI from us. We may charge you a reasonable fee for paper copies of your PHI or the amount of our reasonable labor costs for a copy of your PHI in an electronic format.

    Right to Confidential Communications. You have the right to make a reasonable written request to receive your PHI by alternative and reasonable means of communication or at alternative reasonable locations.

    Right to Receive Paper Copy of NPP. You may at any time request a paper copy of this Notice, even if you previously agreed to receive this Notice by email or other electronic format. Please contact the Privacy Office to obtain a paper copy of this Notice.

    Right to Notice of Breach. We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your PHI through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured PHI and inform you of what steps you may need to take to protect yourself.

    Right to Request Additional Restrictions. You have the right to request restrictions be placed on our use and disclosure of your PHI, such as:

    • For treatment, payment and health care operations,
    • To individuals involved in your care or payment related to your care, or
    • To notify or assist individuals locate you or obtain information about your condition.

    Although we will carefully consider all requests for additional restrictions on how we will use or disclose your PHI, we are not required to grant your request unless your request relates solely to disclosure of your PHI to a health plan or other payor for the sole purpose of payment or health care operations for a health care item or service that you or your representative have paid us for in full and out-of-pocket. Requests for restrictions must be in writing. Please contact the Privacy Office if you wish to request a restriction.

    Right to Request Amendment. You may request that we amend, or change, your PHI that we maintain by contacting Medical Records / Pamela Schwarz. We will comply with your request unless:

    • We believe the information is accurate and complete;
    • We maintain the information you have asked us to change but we did not create or author it, for example, your medical records from another doctor were brought to us and incorporated into your medical records with our doctors;
    • The information is not part of the designated record set or otherwise unavailable for inspection.

    Requests for amendments must be in writing. Please contact the Privacy Office if you wish to request an additional restriction on a use/disclosure of your PHI.

    Right to Revoke Authorization. You may at any time revoke your authorization, whether it was given verbally or in writing. You will generally be required to revoke your authorization in writing by contacting our Privacy Office. Any revocation will be granted except to the extent we may have taken action in reliance upon your authorization.

    Right to Request an Accounting of Disclosures. You may request an accounting of certain disclosures we have made of your PHI from a designated record set within the period of three (3) years from the date of your request for the accounting. The first accounting you request within a period of twelve (12) months is free. Any subsequent requested accountings may result in a reasonable charge for the accounting statement. Please contact the Privacy Office if you wish to request an accounting of disclosures. We will generally respond to your request in writing within thirty (30) days from receipt of the request.

    Right to Request Access Report. You may request an access report of all accesses to your PHI maintained in an electronic designated record set within the period of three (3) years from the date of your request for the access report. The first access report you request within a period of twelve (12) months is free. Any subsequent requested accountings may result in a reasonable charge for the access report. Please contact the Privacy Office if you wish to request an access report. We will generally respond to your request in writing within thirty (30) days from receipt of the request.

    VI. INFORMATION REGARDING THE LENGTH AND DURATION OF THIS NOTICE

    This Notice is effective as of June 1, 2013. We will abide by the terms of this Notice as is currently in effect, however, we may change this notice at any time. Changes to this Notice will apply to all PHI that we maintain. However, if we do change this Notice, we will only make changes to the extent permitted by law. We will also make the revised Notice available to you by posting it in a place where all individuals seeking services from us will be able to read the Notice as well as on our website at http://sbivf.com. You may obtain the new Notice in hard copy as well from our Privacy Office.

    VII. COMPLAINTS/ADDITIONAL INFORMATION

    You may contact our Privacy Office at any time if you wish any additional information or have questions concerning this Notice or your PHI. If you feel that your privacy rights have been or may have been violated, you may also contact our Privacy Office OR file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. We will NOT retaliate against you if you file a complaint with us or the Office of Civil Rights. If you wish to file a written complaint with the Office of Civil Rights, please contact the Privacy Office and we will provide you with the contact information.

    VIII. OUR CONTACT INFORMATION

    You may contact us with any concerns or for additional information regarding our privacy practices by calling or writing the Privacy Office at:

    The Institute for Reproductive Medicine and Science at Saint Barnabas, PA
    Arthur O. Poltrack - Privacy Officer
    94 Old Short Hills Rd., Suite 403, East Wing
    Livingston, NJ 07039
    973-322-2207
    apoltrack@sbivf.com