Egg Donor Application

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At CNY Fertility Center, we are committed to treating and using protected health information about you responsibly. This Notice of health information practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.

Our Duties to You Regarding Protected Health Information:

“Protected health information” is individually identifiable health information and includes demographic information (for example, age, address, etc.), and relates to your past, present or future physical or mental health or condition and related health care services. Our Practice is required by law to do the following: (1) keep your protected health information private and secure; (2) present to you this Notice of our legal duties and privacy practices related to the use and disclosure of your protected health information; (3) abide by the terms of the Notice currently in effect; (4) post and make available to you any revised Notice; and (5) notify affected individuals promptly following a breach of unsecured protected health information.  We reserve the right to revise this Notice and to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. The Notice’s effective date is at the top of the first page and at the bottom of the last page.

How We May Use or Disclose Your Protected Health Information:

Following are examples of permitted uses and disclosures of your protected health information. These examples are not exhaustive.

Required Uses and Disclosures – By law, we must disclose your health information to you unless it has been determined by a health care professional that it would be harmful to you. Even in such cases, we may disclose a summary of your health information to certain of your authorized representatives specified by you or by law. We must also disclose health information to the Secretary of the U.S. Department of Health and Human Services (HHS) for investigations or determinations of our compliance with laws on the protection of your health information.

Treatment – We 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 your protected health information from time-to-time to another physician or health care provider (for example, a specialist, pharmacist or laboratory) who, at the request of your physician, becomes involved in your care, such as a perinatologist managing a high-risk pregnancy.  In emergencies, we will use and disclose your protected health information to provide the treatment you require.

Payment – Your protected health information will be used or disclosed, as needed, to obtain payment for your health care services such as completing a claim form to obtain payment from an insurer. This also may include certain activities we may need to undertake before your health care insurer approves or pays for the health care services recommended for you, such as determining eligibility or coverage for benefits. For example, obtaining approval for insemination, in vitro fertilization, hysterosalpingograms or surgical procedures might require that your relevant protected health information be disclosed to obtain approval to perform these procedures. We will continue to request your authorization to share your protected health information with your health insurer or third-party payor.

Health Care Operations – We may use or disclose, as needed, your protected health information to support our daily activities related to providing health care. These activities include billing, collection, quality assessment, licensing, and staff performance reviews. For example, we may disclose your protected health information to a billing clearing house in order to prepare claims for reimbursement for the services we provide to you. We may call you by first name in the waiting room when your physician is ready to see you. We will share your protected health information with other persons or entities who perform various activities (for example, a genetics testing lab) for our Practice. These business associates of our Practice are also required by law to protect your health information.

Fundraising – We may use or disclose your protected health information as necessary to contact you in order to raise funds for our Practice. Any such communication will tell you how you may opt out of receiving future fundraising communications from us.

Appointment Reminders – We may use and disclose your information in order to contact you as a reminder that you have an appointment.

Treatment Alternatives – We may use and disclose your information to contact you in regard to treatment alternatives or to describe a health-related product or service we provide related to your needs.  CNY Fertility, PLLC offers a wide range of support services, including support groups, workshops, classes, and health-fostering events which we communicate via electronic communications to you.

Limited Marketing – We may use or disclose your protected health information to engage in a face-to-face communication about a product or service we offer or when the communication consists of a promotional gift of nominal value.

Required by Law – We may use or disclose your protected health information if federal, state, or local laws or regulations require the use or disclosure.

Public Health – We may disclose your protected health information to a public health authority who is permitted by law to collect or receive the information. For example, the disclosure may be necessary to prevent or control disease, injury or disability; report births and deaths; or report reactions to medications or problems with medical products. This disclosure is also made when child or adult abuse or neglect or domestic violence is suspected. We may provide proof of immunization without authorization, to your school if (i) the school is required by State or other law to have proof of immunization prior to admission and (ii) we obtain and document your permission or, for a minor, the permission of the parent, guardian or other person acting in loco parentis for the individual.

Communicable Diseases – We may disclose your protected health information, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight – We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, or other regulatory programs.

Food and Drug Administration – We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events; track products, enable product recalls; make repairs or replacements; or conduct post-marketing review.

Lawsuits and Disputes – We may disclose protected health information during any judicial or administrative proceeding, in response to a court order or administrative tribunal (if such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement – We may disclose your protected health information for law enforcement purposes, including information requests for identification and location of suspects, material witnesses and missing persons; for circumstances pertaining to victims of a crime; and criminal activity occurring within CNY Fertility, PLLC.

Coroners, Funeral Directors, and Organ Donations – We may disclose your protected health information to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by law. We may also disclose protected health information to funeral directors as authorized by law. Protected health information may be disclosed to organizations involved in the procurement, banking, or transplantation of cadaver organs, eyes or tissue for the purpose of facilitating donations.

Reproductive Services – We may disclose your protected health information to the New York State Tissue Bank, to authorized employees of the New York State Department of Health (NYSDOH) associated with the Tissue Bank or as otherwise permitted by law.  Your protected health information shall not be disclosed to any other person or entity, except upon written informed consent and authorization by you.

In accordance with the 1992 Fertility Clinic Success Rate and Certification Act, CNY Fertility, PLLC will report data from your assisted reproductive technology cycles to both the Society for Assisted Reproductive Technology (SART) and the Centers for Disease Control and Prevention (CDC.)  The CDC is required by law to collect data on all assisted reproductive technology cycles performed in the United States annually and to report success rates using this data.  Any protected health information maintained by CDC for this purpose will not be re-disclosed without your express written authorization.

Research – Upon your express authorization, we may disclose protected health information to researchers when authorized by law, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Threat to Health or Safety – Under applicable Federal and State laws, we may disclose your protected health information to law enforcement or another health care professional if we believe in good faith that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or that of another person or the public.

Military Activity and National Security – When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for activities believed necessary by appropriate military command authorities to ensure the proper execution of the military mission, including determination of fitness for duty; or to a foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information, under specified conditions, to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or others.

Workers’ Compensation – We may disclose your protected health information for workers’ compensation claims, to comply with workers’ compensation laws and similar government programs that provide benefits for work-related illnesses and injuries.

Inmates – We may disclose your protected health information, under certain circumstances, to a correctional institution if you are an inmate of that correctional facility.

Parental Access – State laws concerning minors permit or require certain disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the laws of New York and will make disclosures following such laws.  CNY Fertility, PLLC will notify any patient over the age of 12 of a request to review his/her protected health information by a qualified person and reserves the right to deny the request should the minor patient object to the disclosure.

Uses and Disclosures of Protected Health Information Requiring Your Permission:

In some circumstances, you can tell us your choices about what protected health information we share.  If you have a clear preference for how we share your information in the situations described below, talk to us.  Tell us what you want us to do, and we will follow your instructions.

Individuals Involved in Your Health Care – You have both the right and choice to tell us to share information with individuals involved in your health care.  Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. We may also give information to someone who helps pay for your care. Additionally, we may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person who is responsible for your care, of your location, general condition, or death. If you should become deceased, we may disclose your protected health information to a family member or other individual who was previously involved in your care, or in payment for your care, if the disclosure is relevant to that person’s prior involvement, unless doing so is inconsistent with your prior expressed preference.

Disaster Relief – You have both the right and choice to tell us to share information in a disaster relief situation.  Unless you object, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest.  We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Disclosures Requiring Express Patient Authorization:

The following uses and disclosures will be made ONLY with your written authorization:

1. Most uses and disclosures of psychotherapy notes.
2. Uses and disclosures of protected health information for marketing purposes, including subsidized treatment communications.
3. Disclosures that constitute the sale of protected health information.
4. Other uses and disclosures not described in this Notice.

In accordance with New York law, any disclosures of information relating to alcohol and drug treatment, mental health treatment, or confidential HIV/AIDS-related information will be made ONLY with your express written authorization and recipients will be notified that they are prohibited from redisclosing such information or using it for another purpose without your express written authorization.

Right to Revoke Authorization – If you execute any authorization(s) for the use and disclosure of your protected health information, you have the right to revoke such authorization(s), except to the extent that action has already been taken in reliance on such authorization.  Requests to revoke authorizations should be made in writing to our Privacy Officer.

Your Rights Regarding Your Health Information:

You may exercise the following rights by submitting a written request to our Privacy Officer. Our Privacy Officer can guide you in pursuing these options. Please be aware that our Practice may deny your request; however, in most cases you may seek a review of the denial.

Right to Inspect and Copy – Within 10 days of your written request, you may inspect and/or obtain a copy of your protected health information that is contained in a “designated record set” for as long as we maintain the protected health information. A designated record set contains medical and billing records and any other records that our Practice uses for making decisions about you. This right does not include inspection and copying of the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding. You may be charged a fee of $.75/page for a copy of your record and we will advise you of the exact fee at the time you make your request.  We may offer to provide a summary of your information and, if you agree to receive a summary, we will advise you of the fee at the time of your request.  Copies of records will not be denied solely because of an inability to pay.  You also have a right to request an electronic copy of your medical and billing records and to direct CNY Fertility, PLLC to transmit this electronic copy to another entity or person designated by you.

Right to Request Restrictions – You may ask us not to use or disclose (share) any part of your protected health information for treatment, payment or health care operations. Your request must be made in writing to our Privacy Officer. In your request, you must tell us: (1) what information you want restricted; (2) whether you want to restrict our use or disclosure, or both; (3) to whom you want the restriction to apply, for example, disclosures to your spouse; and (4) an expiration date. If we believe that the restriction is not in the best interests of either party, or that we cannot reasonably accommodate the request, we are not required to agree to your request. If the restriction is mutually agreed upon, we will not use or disclose (share) your protected health information in violation of that restriction, unless it is needed to provide emergency treatment. You may ask us not to disclose (share) certain information to your health plan. We must agree with that request only if the disclosure is not for the purpose of carrying out treatment (only for carrying out payment or health care operations) and is not otherwise prohibited by law and pertains solely to a health care item or service for which we have been paid out of pocket in full by you or by another person on your behalf other than your health plan. You may revoke a previously agreed upon restriction, at any time, in writing.

Right to Request Alternative Confidential Communications – You may request that we communicate with you about your health information in a certain way or have such communications addressed to a certain location.  For example, you can ask that we only contact you at work or by mail to a PO box.  You must make your request in writing to our Privacy Officer. We will not ask you the reason for your request and all reasonable requests will be accommodated.

Right to Request Amendment – If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected health information as long as we maintain this information. You may not request that information be removed from your record, only that information be added to complete or correct it. While we will accept requests for amendment, we are not required to agree to the amendment.  If we disagree with your requested amendment, we will tell you why in writing within 60 days.  Should your request for amendment be denied, you have the right to submit a statement of disagreement which will become part of your medical record.  If we disagree with your statement, we also have the right to include a note in your record stating why we disagree.

Right to an Accounting of Disclosures – You may request that we provide you with an accounting (list) of the disclosures we have made of your protected health information for up to six years prior to the date you ask, who we shared it with, and why.  This right applies to disclosures made for purposes other than treatment, payment or health care operations as described in this Notice and excludes disclosures made directly to you, to others pursuant to an authorization from you, to family members or friends involved in your care, or for notification purposes.  Your request must clearly identify the period you want the accounting for.  Within 60 days of the date of your request, we will provide you with this accounting.  We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.  Before charging a fee, we will inform you of the amount and allow you an opportunity to withdraw or modify your request to avoid or reduce the fee.  The right to receive this information is subject to additional exceptions, restrictions, and limitations as described earlier in this Notice.

Rights Related to an Electronic Health Record – If we maintain an electronic health record containing your protected health information, you have the right to obtain a copy of that information in an electronic format and you may choose to have us transmit such copy directly to a person or entity you designate, provided that your choice is clear, conspicuous, and specific.  You may request that we provide you with an accounting of the disclosures we have made of your protected health information (including disclosures related to treatment, payment and health care operations) contained in an electronic health record for no more than 3 years prior to the date of your request (and depending on when we acquired an electronic health record).

Right to Obtain a Copy of this Notice – You may view or download a copy of this notice electronically in your Patient Portal.

Special Protections – This Notice is provided to you as a requirement of HIPAA. There are several other New York Public Health and privacy laws that also apply to HIV-related information, family planning information, mental health information, psychotherapy notes, and substance abuse information. These laws have not been superseded and have been taken into consideration in developing our policies and this Notice.

Complaints – Under HIPAA, if we deny your request to inspect or copy your medical record, you may request a review of that decision by another licensed health care professional who was not involved in the original decision. Under New York law, if you have been denied a request to inspect or copy your medical record, you also have the right to have that decision reviewed by a Medical Records Access Review Committee appointed by the Commissioner of Health.  We will abide by the reviewer’s decision. However, you have the right to file suit seeking judicial review of the Medical Records Access Review Committee’s decision in New York State Supreme Court within 30 days of receiving a decision from this Committee to deny access.

If you believe these privacy rights have been violated, you may file a written complaint with our Privacy Officer as described below or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/  No retaliation will occur against you for filing a complaint.

Contact Information – Our Privacy Officer is Deb Woodhouse. She can be contacted at DWoodhouse@cnyfertility.com or by calling 1-800-539-9870.   You may contact our Privacy Officer for further information about our complaint process or for further explanation of this Notice of Privacy Practices.