Effective: April 14, 2003

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.

OUR COMMITMENT TO YOU:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of care and services you receive in our office[s]. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our practice, whether made by practice staff or your personal doctor or midwife. If you are admitted to a hospital under our service, that hospital may have different policies or notices regarding their use and disclosure of your medical information created while you are a patient in their facility.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

THE LAW REQUIRES US TO:

Make sure that medical information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
Follow the terms of the notice that is currently in effect.

WE USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

For Treatment. We provide medical information about you to doctors, nurses, technicians, medical students, midwifery students or other office or hospital personnel who are involved in your care. We also may disclose medical information about you to people outside our office or the hospital who may be involved in your medical care such as other physicians, family members, clergy, or others we use to provide services that are part of your care.
For Payment. We may discuss your medical information with your health insurer to verify your eligibility for benefits, obtain prior authorization, and to bill and receive payment for the treatment and services you receive from us.
For Health Care Operations. We may use and disclose medical information about you for various practice functions such as reviewing the quality of care delivered, education and for planning.
Appointment Reminders and Follow up. We may use and disclose medical information to contact you as a reminder that you have an appointment with us. We may also use information to contact you following a procedure to verify your recovery. If we try to contact you by phone and you are not available, we may leave a message with a family member or on your answering machine.
Bragging Wall. We display any pictures of your new baby that you may send to us for all of our patients to see.
Business Associates. We may provide your medical information to outside parties so they can perform certain functions or services on our behalf. Each Business Associate must sign a contract with us before we send them any information. That contract requires them to protect the confidentiality of your medical information.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
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 that of another person or the public.
Organ and Tissue Donation. If you are an organ donor or potential recipient, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donor bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities.
Workers' Compensation. We may release medical information about you for workers' compensation or similar programs.
Public Health Risks. We may disclose medical information about you for public health activities. These activities may include: the prevention or control of disease, report births and deaths, report child abuse or neglect, to notify people of recalls, and to report reactions to medications.
Health Oversight Activities. We may disclose medical information to health oversight agencies for activities authorized by law. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judical Proceedings. 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 someone else, after reasonable efforts to notify you or to obtain a protective order.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official, to identify or locate a suspect, witness or missing person, or victims of crime (with your consent in some circumstances), to report deaths from criminal conduct, crimes on the premises or, in emergencies, to report a crime.
Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner, medical examiner or funeral director to identify a deceased person, determine cause of death, or as reasonably necessary to carry out their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

YOU HAVE THE FOLLOWING RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Privacy Officer, Obstetrics-Gynecology & Infertility Group, P.C., 136 Sherman Avenue, New Haven, CT. 06511.. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Practice will review your request and denial. We will comply with the outcome of the 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 hospital. You should contact 203-401-6137 X704 or privacyofficer@ob-gyn-infertility.com to discuss this process.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. You should contact 203-401-6137 x704 or privacyofficer@ob-gyn-infertility.com to discuss this process.
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 we limit the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You must make your request in writing to Privacy Officer, Obstetrics-Gynecology & Infertility Group, P. C., 136 Sherman Avenue ,Suite 502, New Haven, CT 06511.
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 work or by mail. You must make your request in writing to Privacy Officer, Obstetrics-Gynecology & Infertility Group, P.C., 136 Sherman Avenue, Suite 502, New Haven, CT 06511.
Right to a Paper Copy of this Notice. You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, ask for it at the front desk.

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 any information we receive in the future. We will post a copy of the current notice in the office. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice contact the Privacy Officer at (203) 401-6137 X704 or privacyofficer@ob-gyn-infertility.com.. 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 reason 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.