In accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), this Notice describes how your Protected Health Information (PHI) may be used and disclosed and how you can get access to this information. Please review it carefully.
For more information, please see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Northern Illinois & Wisconsin region: https://viosfertility.com/northern-illinois-wisconsin-region/
Southern Illinois & Missouri region: https://viosfertility.com/missouri-southern-illinois-region/
- We must provide you with this Notice and follow the duties and privacy practices described within it.
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 posted in our office and on our website. You may receive a copy upon request.
- We must maintain the privacy and security of your PHI.
- We will not use or share your PHI other than as described here without your written Authorization.
- We will notify you if a breach occurs that may have compromised the privacy or security of your PHI.
Ways in which we use and disclose your PHI (continued on page 2)
For more information, go to www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
For treatment: We can use your PHI for healthcare and related services within Vios and may share your PHI with others involved in your care. For example:
- We may share your PHI with your OB/GYN, PCP, genetic counselor or other healthcare providers.
- We may share your PHI with labs, pharmacies, imaging facilities, surgical facilities and other organizations and facilities utilized in your care.
For payment: We can use and share your PHI for billing and payment purposes. For example:
- We may share your PHI with your health insurance company to facilitate prior-authorization and/or payment for services.
- We may share your health insurance information with a lab to facilitate billing for tests we have ordered.
For healthcare operations: We can use and share your PHI for healthcare operations, which are certain administrative, financial, legal and quality improvement activities that are necessary to run our business and to support the core functions of treatment and payment. For example:
- We may use your PHI to evaluate our protocols.
- We may share your PHI with medical students/residents under the supervision of a Vios physician.
For reporting our data and outcomes to the Society for Assisted Reproductive Technology (SART).
For public health and safety issues: We can use and share your PHI for certain situations such as:
- Preventing disease.
- Helping with product recalls.
- Reporting adverse reactions to medications.
- Reporting suspected abuse, neglect or domestic violence when applicable per law.
- Preventing or reducing a serious threat to anyone’s health or safety.
For research: We can use or share PHI for health research without your Authorization in limited circumstances: under a waiver of the Authorization requirement, as a limited data set with a data use agreement, preparatory to research and for research on decedents’ information.
For compliance with the law: We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy laws. We are also required to report certain infectious diseases such as HIV, Hepatitis B &C, Gonorrhea, Chlamydia and Syphilis, to the health department.
For organ and tissue donation requests: We can share your PHI with organ procurement organizations.
To work with a medical examiner or funeral director: We can share PHI with a coroner, medical examiner and/or or funeral director when an individual dies.
For workers’ compensation, law enforcement and other government requests: We can use and share your PHI for certain situations such as:
- For workers’ compensation claims.
- For law enforcement purposes or with a law enforcement official.
- With health oversight agencies for activities authorized by law.
- For special government functions such as military, national security and presidential protective services.
For response to lawsuits and legal actions: We can share your PHI in response to a court or administrative order, or in response to a subpoena.
For collaboration with our business associates: A business associate is an individual or entity that performs functions or activities on behalf of a covered entity that require access to PHI. Vios, a Covered Entity, may utilize business associates for services such as legal, actuarial, accounting, consulting, data aggregation and storage, management, administrative, accreditation, benefits verification and financial. In accordance with HIPAA, Vios requires a fully-executed Business Associate Agreement, which is a legal contract that defines the parameters for the business associate’s use, handling, protection of and responsibility for PHI, before PHI is shared.
Ways in which your PHI can be used and disclosed unless you object
- We may share your PHI with your partner/spouse, family and/or friends if you are present and do not object.
- We may share your PHI with an entity assisting in a disaster relief effort if you do not object.
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
If you are not able to tell us your preference, for example if you are unconscious, we may share your PHI if we believe it is in your best interest. We may also share your PHI when needed to lessen a serious and imminent threat to health or safety.
Ways in which your PHI can be used and disclosed only with your written Authorization, unless required by law
- Sharing PHI with your partner/spouse, family and/or friends when you are NOT present. You will be asked to complete an “Authorization- Communications” form prior to initiating treatment with us so that we know how you would like us to handle this.
- For marketing purposes and/or the sale of your PHI.
- Disclosing your general health information to third parties other than as described on pages 1 &2 of this Notice.
- Disclosing your HIV/AIDS-related information to third parties.
- Disclosing your STD-related information to third parties.
- Disclosing your genetics-related information to third parties.
- Disclosing records defined by HIPAA as Psychotherapy Notes to third parties.
- Re-disclosing to third parties any alcohol and/or substance use disorder treatment records which we received from an alcohol and/or substance use disorder treatment facility, other than in an emergency.
- Re-disclosing to third parties any mental health and/or developmental disability records which we received from a mental health provider, agency or treatment facility.
- Any other disclosure not permitted under Federal or State patient privacy laws.
Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record. Please note that we are not required to allow you access to psychotherapy notes or to any information compiled in reasonable anticipation of, or for use in, legal proceedings. We are also not required to allow you access to information if we believe that such access might harm you or someone else; you have the right to have such denials reviewed by a licensed health care professional for a second opinion.
- Please ask us for an “Authorization for Use and Disclosure of PHI” form for you to complete and sign.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Request a correction to your medical record: You can ask us to correct health information about you that you think is incorrect or incomplete.
- Please ask us for a “Request to Correct Medical Record” form for you to complete and sign.
- We may decline 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, to only contact you at one specific phone number or to send mail to a different address.
- Please ask us for a “Request Confidential Communications” form for you to complete and sign.
- We will agree to all reasonable requests that we are able to accommodate.
Request a restriction on the use and disclosure of your PHI: You can ask us not to use or share certain health information for treatment, payment or healthcare operation purposes.
- Please ask us for a “Request to Restrict Use and Disclosure of PHI” form for you to complete and sign.
- We are not required to agree to your request, and we may decline if it would negatively affect your care.
- If you pay for a service or healthcare item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree unless a law requires us to share that information.
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 health information for six years prior to the date you ask, with whom we shared it and why.
- Please ask us for a “Request for Accounting of PHI Disclosures” form for you to complete and sign.
- We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
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 health information.
- Please provide us with written documentation of this, so that we can make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your privacy rights are violated
- If you feel we have violated your privacy rights, please contact us using the information on page 1.
- 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 hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Please notify Vios in writing of any changes to how you Authorize Vios to use and disclose your PHI.