Email Address of Patient or Personal Representative

                                       
Signature of Patient or Personal Representative                                 Printed Name of Patient or Personal Representative

                                      
Date                                                                                                    Description of Personal Representative’s Authority

IT MAY BE NECESSARY FOR US TO CONTACT YOU BY CALLING YOUR HOME, WORK , CELL OR EMERGENCY NUMBER OR BY EMAILING YOU FOR APPOINTMENTS AND RESULTS.  IF YOU ARE NOT AVAILABLE, WE MAY LEAVE A MESSAGE FOR YOU TO CONTACT THE OFFICE.  UNLESS YOU HAVE SPECIFICALLY INSTRUCTED US NOT TO, WE WILL ASSUME THAT YOU DO NOT OBJECT.  YOU MUST ALSO NOTIFY US IF YOU DO NOT WISH TO DISCUSS YOUR MEDICAL CONDITION WITH IMMEDIATE FAMILY MEMBERS.  THANK YOU.

I PREFER TO BE CONTACTED AT (PLEASE CIRCLE):   

HOME NUMBER  –   WORK NUMBER  –   CELL NUMBER  –   EMERGENCY NUMBER  –   EMAIL –   ALL ARE OK

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(For internal use where signature above cannot be obtained.)

Except in emergency treatment circumstances, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that we make a good faith effort to obtain written acknowledgment of the patient’s receipt of the Notice of Privacy Practices on the first date after April 14, 2003 we provide treatment, products or services to the patient (including at the time of admission, at a first visit to a hospital department, or any other first service contact with the patient).  We must make a good faith effort to obtain written acknowledgment when reasonably practicable following an emergency treatment situation.  If such acknowledgment cannot be obtained, we must document our good faith efforts to obtain the acknowledgment and why it was not obtained.

Describe good faith efforts to obtain written acknowledgment (include your name and the date):

1.   Name:                       Date:  

2.   Name:                       Date:  

3.   Name:                       Date:  

THE ORIGINAL OF THIS FORM MUST BE PLACED IN THE MEDICAL RECORD.

MMC REPRODUCTIVE ENDOCRINOLOGY FPP
‘DBA’ GENESIS FERTILITY & REPRODUCTIVE MEDICINE

NOTICE OF PRIVACY PRACTICES

State and federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice.  We must follow the privacy practices as described below.  This Notice will take effect on April 14, 2003 and will remain in effect until it is amended or replaced by us.

It is our right to change our privacy practices, provided law permits the changes.  Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request.  We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.

You may request a copy of our Privacy Notice at any time by contracting our Privacy Officer Michael Pagliuca.  Information on contracting us can be found at the end of this Notice.

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

We will keep your health information confidential, using it only for the following purposes:

Treatment:  We may use your health information to provide you with our professional services.  We have established “minimum necessary or need to know” standards that limit various staff members’ access to your health information according to their primary job functions.  Everyone on our staff is required to sign a confidentiality statement.

Disclosure:  We may disclose and/or share your health information with other health care professionals who provide treatment and/or service to you either at Maimonides Medical Center or at other facilities or offices.  These professionals will have a privacy and confidentiality policy like this one.  Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Payment:  We may use and disclose your health information to seek payment for services we provide to you.  This disclosure involves our business office staff and may include other providers who treat you, as well as insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.

Emergencies:  We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death.  If at all possible we will provide you with an opportunity to object to this use or disclosure.  Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care.  We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations:  We will use and disclose your health information to keep our practice operable.  Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers, health care providers who treat you and individuals performing similar activities.

Required by Law:  We may use or disclose your health information when we are required to do so by law (e.g. court or administrative orders, subpoena, discovery request or other lawful process).  We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect:  We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities:  We will disclose your health information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.

Marketing Health-Related Services:  We will not use your health information for marketing purposes unless we have your written authorization to do so.

National Security:  The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances.  If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.

Thank You Cards and Birth Announcements:  We may post the cards and announcements that you send to us in our facility for public viewing.  If you would not like us to post your cards or announcements, you must indicate this to us either verbally or in writing.

Electronic Mail:  If you would like to communicate with our staff via electronic mail, please be aware of the following:

• Email should never be used for emergency problems.  In the event of an emergency, please call 911.
• Email should never be used for urgent problems.  In these cases, you should go to an urgent care or immediate care facility.
• Email should be concise.  If you have a problem that is too complex or sensitive to discuss via email, you should make an appointment by calling 718-283-8600.
• Fees may be assessed for any communications or consultations with a physician or other clinical staff member via email.  However, fees shall not be assessed for questions involving general information such as clinic hours, location of the clinic, etc.
• The physicians and other clinical staff members offer you the opportunity to communicate via email.  Transmitting health information by email, however, has a number of risks you should consider before using email to communicate with the clinical staff.  These include, but are not limited to, the following risks:
  • Email can be circulated, forwarded, and stored in numerous paper and electronic files.
  • Email can be immediately broadcast worldwide and be received by unintended recipients.
  • Email senders can easily type in the wrong email address.
  • Email is easier to falsify than handwritten or signed documents.
  • Backup copies of email may exist even after the sender or the recipient has deleted his or her copy.
  • Employers and on-line services have a right to archive and inspect emails transmitted through their systems.
  • Email can be intercepted, altered, forwarded, or used without authorization or detection.
  • Email can be used to introduce viruses into computer systems.
  • Email can be used as evidence in court.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access:  Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian).  There will be some limited exceptions.  If you wish to examine your health information, you will need to complete and submit an appropriate request form.  Contact our Privacy Officer for a copy of the Request Form.  You may also request access by sending us a letter to the address at the end of this Notice.  Once approved, an appointment can be made to review your records.  Copies, if requested, will be available for a nominal charge for each page and the staff time will not be charged.  If you would like the copies mailed to you, postage will be charged.  If you prefer a summary or an explanation of your health information, we will provide it for a fee.  Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.

Amendment:  You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete.  Your request must be in writing and must include an explanation of why the information should be amended.  Under certain circumstances, your request may be denied.

HIPAA Notice of Privacy Practices – This form does not constitute legal advice and covers only federal, not state, law.

Non-routine Disclosures:  You have the right to receive a list of non-routine disclosures we have made of your health care information.  When we make routine disclosures of your health information to a professional for treatment and/or payment purposes, the disclosures are not necessarily recorded.  Therefore records of routine disclosures are not available.  You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment, or healthcare operations.

Restrictions:  You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions.  However, if we do agree to the additional restrictions, we will abide by our agreement, except in cases of emergencies.  Please contact our Privacy Officer if you would like to further restrict access to your health information.  This request must be submitted in writing.

QUESTIONS AND COMPLAINTS

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies, if you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information.  To file a complaint, please request a Complaint Form from our Privacy Officer.  We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

HOW TO CONTACT US

Practice Name:  MMC Reproductive Endocrinology, FFP ‘DBA’ Genesis Fertility & Reproductive Medicine
Privacy Officer:  Michael Pagliuca
Telephone: (718) 283-8600
Address:  1355 84^th Street, Brooklyn, NY  11228

PLEASE NOTE – by submitting this form, you acknowledge and agree to all the above information