HIPAA Notice and Consent
Effective Date: February 9, 2018
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 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 and 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 Protected Health Information 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.
For more information see: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
You have a right to:
- 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. To do so, send us an email at firstname.lastname@example.org. 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.
- 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. To do so, send us an email at email@example.com. 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.
- Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- 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). 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 firstname.lastname@example.org. 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.
- 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 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. We can use and disclose your information to run our organization and contact you when necessary. 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. For more information see: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues. We can share your PHI for certain situations such as:
- preventing disease;
- reporting adverse reactions to medications;
- reporting suspected abuse, neglect, or domestic violence; or
- preventing or reducing a serious threat to anyone’s health or safety.
Do research. We can use or share your PHI for health research.
Comply 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 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 in response to a subpoena.
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 email@example.com.