HIPAA Notice and Consent
Effective Date: November 30, 2023
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.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Stork Club must take measures to protect the privacy of your “Protected Health Information” (“PHI”). PHI includes information we have created or received, in any form or medium (electronic, oral, or paper) regarding your health or payment for your health, that may be used to identify you, and that relates to (a) your past, present, or future physical or mental health or condition, (b) the provision of health care to you, or (c) your past, present, or future payment for the provision of health care.
Under federal law, we are required to:
- Maintain the privacy or security of your PHI
- Let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI
- Follow the duties and privacy practices described in this notice
- Give you a copy of this notice
In certain cases, state law gives more protection to PHI than federal law, and vice versa. In each case, we will apply the laws that protect PHI the most.
Stork Club will not use or share your PHI other than as described in this notice unless you tell us in writing that we can. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
You have the following rights relating to your PHI. You may exercise your rights by submitting a written request to us at firstname.lastname@example.org specifying the right(s) you wish to exercise.
- Access your health and claims records. You can ask to see or get a copy of your health and claims records and other health information we have about you that is kept in a “designated record set.” A “designated record set” is a group of records that includes billing records and records used to make decisions about you and that are maintained by us in a form and format that you request, to the extent such form and format is readily producible by us. If your PHI is maintained in an electronic format, you are permitted to receive access to information you requested in electronic format or may have the information transmitted electronically to a designated recipient. You may be charged a reasonable fee for the cost of copying, mailing or other expenses associated with your request. If we deny your access, you may ask for our decision to be reviewed. We will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied the request. We will comply with the outcome of the review. There are some exceptions to your rights to inspect and copy, such as:
- Psychotherapy notes (if any);
- Information compiled in anticipation of a civil, criminal, or administrative action or proceeding; and
- Situations in which a licensed health care professional determines that releasing the information may have a harmful effect on you or another individual.
- With a few exceptions, we will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
- Right to request restrictions. You have the right to request that we restrict the uses or disclosures of your information PHI for purposes of treatment, payment, or health care operations. You may also request that we limit the information we share about you with a relative or friends. Such uses and disclosures do not typically require your authorization because we may need to use or disclose your PHI in order to provide services to you. We will consider your request for a restriction, however, in most cases, we are not legally required to agree to any restriction that you request. We are only required to agree to a requested restriction of a disclosure to your health plan if (1) the disclosure is for payment or healthcare operations and (2) the information pertains solely to any item or service that you (or another person on your behalf, other than a health plan) paid for out of pocket, in full. To the extent that we do agree to any restriction on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
- Right to choose how we contact you. You have the right to ask that we send your information at an alternative address or by an alternative means, and we will agree to all reasonable requests. For example, you can ask that we only contact you by mail or at work. Request must be made in writing; you do not need to give us a reason for your request. We must will agree to your request as long as it is reasonably easy for us to do so. When appropriate, we may condition the provision of a reasonable accommodation upon receiving information relating to how payment arrangements will be made.
- Ask us to correct health and claims records. You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Your request for a correction must include a reason to support your request. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
- Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
- Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your PHI for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make or disclosures to you). We’ll provide one accounting a year for free. If you request another accounting during the same year, we may charge you a reasonable, cost-based fee.
- Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
- Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will make sure the person has this authority and can act for you before we take any action.
- File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting the Privacy Officer at email@example.com. You can file a complaint 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 https://www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
- Right to receive notification of a breach. You have the right to receive a notification from us if there is a breach of your unsecured PHI.
- For certain health information, you can tell us your choices about what 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.
You have both the right and choice to tell us to: share information with your family, close friends, or others involved in payment for your care; or share information in a disaster relief situation.
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.
Unless you give us written permission, we may not sell your information, or share your information for marketing purposes.
We may use or disclose your PHI without your authorization for purposes of your treatment, for payment purposes, and for other health care operations as explained below. We typically use or share your PHI in the following ways.
Help manage the health care treatment you receive. We can use your PHI and share it with professionals who are treating you. For example, a doctor may send us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization/health care operations. We can use and disclose your information to run our organization and contact you when necessary. These uses and disclosures are necessary to make sure that you receive quality care and to operate and manage our office. For example, we may use PHI about you to develop better services for you. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Pay for your health services. We can use and disclose your PHI as we pay for your health services. For example, we may share information about you with your health plan administrator to coordinate payment for health services you have received.
Administer your plan. We may disclose your PHI to your health plan sponsor for plan administration.
We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your PHI for these purposes. We may use or disclose your PHI in the following ways:
Help with public health and safety issues. We can share your PHI for certain situations such as:
- preventing disease;
- to notify people of recalls of products they may be using;
- reporting adverse reactions to medications; or
- preventing or reducing a serious threat to anyone’s health or safety.
Victims of abuse, neglect, or domestic violence. We may disclose PHI to a government authority including a social service or protective services agency, about suspected abuse, neglect, or domestic violence.
Do research. We can use or share your PHI for health research that has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Comply with the law. We may share your PHI to the extent that use or disclosure is required by state or federal, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director. We can share your PHI with organ procurement organizations. We can share PHI with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. We can use or share your PHI: 1) for workers’ compensation claims; 2) for law enforcement purposes or with a law enforcement official; 3) with health oversight agencies for activities authorized by law; 4) for special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions. We can share your PHI in response to a court or administrative order, or if certain conditions are met, in response to a subpoena, discovery request, or other lawful process.
Threats to health or safety. Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
In the following situations, we may disclose a limited amount of your PHI as long as you do not object and the disclosure is not otherwise prohibited by law.
Individuals involved in your care or payment for care. If you consent, do not object, or we reasonably infer that there is no objection, we may disclose PHI about you to a family member, personal representative or other person identified by you who is involved in your health care or payment for your health care. If you are incapacitated or it is an emergency, we will use our professional judgment to determine whether disclosing PHI is in your best interest under circumstances. This includes in the event of your death unless you have specifically instructed us otherwise. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care.
Right to Request Restrictions for Disclosures Related to Self-Payment. You have the right to request the non-disclosure of health information to a health plan for treatment in situations where you have paid in full out-of-pocket for a health care item or service.
Patient Directories. Your name, location, and general condition may be put into our patient directory for disclosures to callers or visitors who ask for you by name.
For uses and disclosures for purposes other than treatment, payment and health care operations, we are required to obtain your written authorization, unless the use or disclosure falls within one of the exceptions described above. Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute the sale of PHI require your authorization. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already relied on your authorization.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.
Stork Club Fertility, Inc. (“Stork Club”), as part of administering the Stork Club program (the “Services”), may have access to and use my personal health information (“PHI”), which I provide to Stork Club as part of my participation in the Services. Stork Club also manages the Stork Club Community (the “Community”), in which I may choose to participate, and in so doing may choose to share information about myself. I understand that if I so share such information, other participants in the Community may also be able to see my information, including PHI that I post and/or disclose in the course of engaging with the Community.
You acknowledge that you have read, understand and agree to the terms of the Consent to Share and Release such Information.
If you have any questions about this notice, please contact us at firstname.lastname@example.org.