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.
(v.5.13.2)
Uses and Disclosures:
Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Genetic information cannot be disclosed for underwriting purposes.
Payment: Your health information may be used to seek payment from your health plan, from an insurance company or other third party. Your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. However, if you pay in full, out of pocket, you have the right to restrict disclosure of your protected health information to your health plan.
Health Care Options: It may be necessary for the doctor and members of the staff of Chicago IVF, Ltd. to use your health information, examination, and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
Business Associate: It may be necessary to disclose your protected health information to business associates that assist in administrative, billing, claims, and other health services. Each business associate must agree in writing to ensure your confidentiality and security.
Additional circumstances in which your information may be disclosed without your authorization:
- A request from a personal representative who may assist you in obtaining care
- Notifying agencies of reports of abuse, neglect or domestic violence
- Compliance with legal proceedings such as court or administrative orders or subpoena
- Law enforcement purposes
- Workers compensation
- Records of deceased patients to persons authorized under applicable law
- Governmental agencies authorized to oversee health care systems or government programs.
- To the US Department of Health and Human services for auditing purposes.
Right to opt out of Fundraising: You have the right to opt out of fundraising, if Chicago IVF contacts you for any or such purposes.
Complaints: If you would like to submit a comment or complaint about our privacy practices, you can do so by submitting your concerns to: Privacy Officer, Advanced Reproductive Health Centers, Ltd. 5225 Old Orchard Road, Suite 24A, Skokie, IL 60077. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 233 N. Michigan Ave., Suite 240, Chicago, IL 60601 within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
Effective Date: This notice is effective on or after September 23, 2013
Changes to this notice: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
Other Uses and Disclosures require your authorization:
Disclosure of your health information or its use for any purpose other than those listed requires your specific written authorization. (1) most uses and disclosures of psychotherapy notes (where appropriate); (2) uses and disclosures of Protected Health Information for marketing purposes; and (3) disclosures that constitute a sale of Protected Health Information You may revoke such authorization, but the revocation must be in writing. Please note: Your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Your Rights under the Federal Privacy standards:
Right to request restrictions: You have the right to request a restriction or limitation on the use of your protected health information.
Right to request Confidential Communications: You have the right to request that you receive communications of your protected health information from Advanced Reproductive Health Centers. Ltd. Your request must specify how you may be contacted in private.
Right to inspect and copy: You have the right to inspect or obtain a copy of your protected health information in requests by writing or in electronic form by contacting our Privacy Officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
Right to request an amendment: You have the right to request an amendment to your protected health information or submit corrections.
Right to an accounting of disclosure: You have the right to receive request an accounting of how and to whom your protected health information has been disclosed.
Right to be notified when a breach has occurred: You have the right to be notified when a breach of your protected health information has occurred.
Right to a paper copy of this notice: You have the right to request a paper copy of this notice at any time.
Chicago IVF, Ltd. Duties: We are required by law to maintain the privacy of your protected health information and to provide you with this notice. We are also required to abide by the privacy policies and practices that are outlined in this notice.
Our Privacy Pledge: We want you to understand that we respect your privacy. Other than the necessary uses and disclosures we described above, we will not sell your health information or provide any of your health information to any outside marketing company.