***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 Medical Record
Your medical record (chart) contains your symptoms, examination, test results, diagnoses, treatment, and plan for follow–up. This is protected health information (PHI) and is used for many reasons. Your medical record serves as a:
- Basis for planning your care and treatment (this includes scheduling and appointment reminders)
- Means of communication among the many health professionals who contribute to your care
- Legal document describing the care you received
- Means by which you or a third-party payer can verify services billed
- Tool in educating health professionals
- Source of data for quality control programs and medical research
- Source of information for public health officials (by law, certain illnesses must be reported)
Your Health Information Rights
Although your medical record (chart) is the physical property of the fertility clinic, the information contained within the record belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information
- Obtain a paper copy of this notice
- Inspect and obtain a copy of your medical record
- Amend your health record (requests must be made in writing)
- Request communication of your health information by alternative means or at alternative locations
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
- Obtain an account of any non-routine disclosures of your health information
For More Information or to Report A Problem
Please call during regular office hours with any concerns. If you believe that your privacy rights have been violated, you can file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized in any way for filing a complaint.
ABOUT LANE FERTILITY INSTITUTE
