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 PRIVACY POLICY

FOX VALLEY REPRODUCTIVE MEDICINE, S.C. NOTICE OF PRIVACY PRACTICES

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.


Your Health Care Information - Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.

FVRM's Responsibilities
It is your right as a patient to be informed of FVRM's legal duties with respect to protection of the privacy of your personal health information.

FVRM is required to: Maintain the privacy of your health information; Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; Abide by the terms of this notice.

FVRM reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. FVRM also reserves the right to change the terms of its notice with respect to any applicable more limited uses and disclosures. FVRM will promptly revise and distribute its notice whenever FVRM makes a substantial change to any of its privacy practices. FVRM will not use or disclose your health information without your authorization, except as described in this notice.

Your Health Information Rights
You have the right to: Request a restriction on certain uses and disclosures of your health information. You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or FVRM's payment or health care operation activities. However, FVRM is not required to agree to your requested restriction. For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area. Receive confidential communications. You have the right to request that FVRM communicate your health information to you by alternative means or at alternative locations. FVRM shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record. FVRM will present a form, which you will complete and sign regarding these communications. Inspect and obtain a copy of your health record. You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing to the Designated Medical Records person or Office Manager. This right may not apply to certain types of psychotherapy notes. FVRM will supply you with one copy of your medical records per year at no cost. Amend your health record. You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You will be asked to make this request in writing and state the reason why your health record should be changed. If FVRM did not create the health information you believe is incorrect or if FVRM disagrees with you, FVRM may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended. Obtain an accounting of disclosures of your health information. You have the right to an accounting of disclosures of your health information that FVRM has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, to whom the disclosure is being made, a brief description of information disclosed and the reason for disclosure. FVRM will provide you with one copy per year at no charge. Obtain a paper copy of the notice upon request. You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that FVRM provide a paper copy of the notice.

Uses and Disclosures for Treatment, Payment and Health Care Operations
FVRM is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations. FVRM may use or disclose your health information for treatment. FVRM may use or disclose your health information in the provision, coordination or management of your health care. Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment. Example: FVRM may use your health information to provide you with an appointment reminder. Refer to "Designated Routing of Information Form." Example: FVRM may send you information about treatment alternatives or other health related services that may be of interest to you. Example: FVRM may send updated ACOG forms to the appropriate OB department during pregnancy. FVRM may use or disclose your health information for payment. FVRM may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment. Example: FVRM may use or disclose your information to your insurer to obtain payment for the provision of health care services. FVRM may use or disclose your health information for routine health care operations. FVRM may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, FVRM may use or disclose your health information for the following purposes: As Required by Law: FVRM may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following: Disclosures about victims of elderly or child abuse; Disclosures for judicial and administrative proceedings; or Disclosures for law enforcement purposes.

Public health: As required by law, FVRM may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting. FVRM may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability. FVRM may disclose your protected health information excluding your HIV test result without your authorization to a county agency investigating child abuse. FVRM may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result without your authorization to the Food and Drug Administration (FDA). FVRM may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV. FVRM may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers' compensation has been filed. Victims of abuse, neglect or domestic violence: FVRM may disclose health information except for an HIV test result if FVRM reasonably believes that an individual is a victim of child or elderly abuse.

Health oversight activities: FVRM will not disclose HIV test results to health care oversight agencies without an authorization. FVRM may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.

Judicial and Administrative Proceedings: FVRM may disclose your protected health information in response to a court order. FVRM may disclose your protected health information in response to a subpoena if FVRM is a party to a court action, FVRM has received your authorization to disclose and has not complied within two business days or FVRM failed to respond to a request for workers' compensation records. FVRM may disclose your protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.

Law enforcement: FVRM may disclose your protected health information except for HIV test results to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. FVRM may disclose your protected health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. FVRM may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. FVRM may disclose your protected health information to a law enforcement official in response to a court order.

For activities related to death: Coroner or Medical Examiner: FVRM may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner.

Funeral Director: FVRM may use or disclose your HIV test result to a funeral director.

For cadaveric organ, eye or tissue donation purposes: FVRM may use or disclose your HIV test result to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

Research: FVRM may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law. FVRM will require written authorization.

To avoid a serious threat to health or safety: FVRM may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.

Disclosures for specialized government functions: FVRM may disclose protected health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result for national security, for protection of the President and for medical suitability determination of Armed Forces personnel to a state or federal agency. FVRM may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.

Workers' compensation: FVRM may disclose protected health information reasonably related to a workers' compensation injury.

FVRM has attempted to explain with this notice the circumstances where state law may be more protective than the federal privacy rule and provides greater privacy protection. Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires FVRM to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to FVRM's Privacy Officer.

Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with FVRM or with the Secretary of the Department of Health and Human Services. This Complaint must be in writing. There will be no retaliation against you for filing a complaint. To file a complaint with FVRM please contact the FVRM's Privacy Officer/Office Manager who will provide you with the necessary assistance.

Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Privacy Officer/Office Manager
Fox Valley Reproductive Medicine, S.C.
47 Park Place, Suite 100
Appleton, WI 54914
920-560-5585 Phone
920-560-5588 Fax
866-200-6546 Toll Free

Effective Date: This Notice of Privacy Practice is effective on or before December 3, 2007.