Patient Rights and Responsibilities at West Coast Fertility Centers

Patient Rights:

We respect the rights of our patients and recognize that each person is an individual with different needs. To the extent possible, we will provide:

  1. Equitable, unbiased, considerate and respectful care by competent personnel in a safe environment.
  2. Treatment without discrimination as to your race, age, religion, sex, sexual orientation, national origin, ability to pay, or illness. Patients are provided appropriate privacy regarding medical records and during interviews, examination, treatment, and consultation. Be assured you will receive physical privacy that is appropriate to the medical care. Medical information will not be released without patient’s written consent.
  3. The opportunity to participate in decisions involving your health care.
  4. Complete and current information concerning your diagnosis, treatment and prognosis to you or your designee.
  5. Informed consent process for any and all treatments and procedures (with the exception of emergency medical care). The informed-consent process includes an explanation of the treatment or procedure; any alternative treatments or procedures; the intent, and possible complications of the treatment or procedure; and the anticipated outcome.
  6. Complete and adequate discharge instructions after treatment to insure continuity of care.
  7. Explanation of the cost for testing and treatment and explanation of your bill.
  8. The opportunity to submit any concerns in writing and to receive an appropriate response.
  9. The opportunity, if you wish, to formulate advance directives and appoint someone else to make health care decisions to the extent permitted by law.

Patient Responsibilities:

Prospective patient have certain responsibilities to ensure we are prepared to offer the care you need.

  1. Cooperate with the physicians and health care providers. All prospective patients, male or female, treated at WCFC must disclose any current or past medical condition including the use of prescription medications, illicit or recreational drugs, rehabilitation treatments, psychiatric conditions, drug addictions past or present. Provide our physicians and staff with a complete and honest history about illnesses, hospitalizations, medications and other matters related to your health. Please be truthful accurate in all information you provide us.
  2. All persons undergoing testing or treatment at WCFC must present a current, valid, government issued photo identification which must be acceptable to the administrative staff.
  3. All patients must be compliant with statutory reproductive regulations in California.
  4. All patients must conduct themselves in a professional manner, treating WCFC staff with respect and courtesy. WCFC reserve the right to terminate service to any patient by providing 30 days notice.
  5. You are expected to arrive promptly for appointments or provide timely notice when cancelling.
  6. Please be patient when an appointment is delayed; keep in mind that an emergency may be taking place.
  7. All financial obligations must be met before any treatment can be started. If unsure, please ask.
  8. Notify WCFC if there is any problem or dissatisfaction with care or services.
  9. Patients with children are asked to respect the feelings of those who are struggling with infertility. Kindly make arrangements for childcare in your home.
  10. Everyone’s time is valuable. When cancelling an appointment, we require 48 hours to avoid a $100 fee.

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.

This Medical Center is required to maintain the privacy of your Protected Health Information (“PHI”) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic demographic information, that may identify you and that relates to your past, present or future related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.

This Medical Center is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for PHI we maintain. Upon request, we will provide a revised Notice to you.

Your Health Information Rights

You have the following rights with respect to PHI about you:

  • Obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact the “Privacy Officer” whose name appears at the end of this notice.
  • Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use of disclosure of PHI about you by sending a written request to the “Privacy Officer” whose name appears at the end of this notice. We are not required to agree to those restrictions.
  • Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as the Medical Center maintains the PHI. The “designated record set” usually will include chart notes, treatment rendered, laboratory data, surgical information and billing records. To inspect or copy PHI about you, you must send a written request to the “Privacy Officer” whose name appears at the end of this notice. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.
  • Request an amendment of PHI. If you feel that the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the “Privacy Officer” who name appears at the end of this notice. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we give a rebuttal to your statement.
  • Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment or health care operations. The accounting will exclude certain disclosures such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to the “Privacy Officer” whose name appears at the end of this notice. Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
  • Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about the medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit your request in writing to the “Privacy Officer” whose name appears at the end of this notice. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.
  • Examples of How We May Use and Disclose PHI

    The following are descriptions and examples of ways we use and disclose PHI:

    We will use PHI for reporting of medical treatment and outcome. Example: Information obtained by the Medical Center will be reported to the Center for Disease Control in conjunction with the Society for Reproductive Assisted Technologies for the purpose of monitoring types of infertility treatment received by age specific groups at this clinic. This process is anonymous but certain demographical, treatment specific and related treatment outcome information will be released.

    We will use PHI for payment. Example: We will contact your insurer or pharmacy benefit manager to determine whether it will pay for your treatment/medications and the amount of your co-payment. We will bill you or a third-party payor for the cost of treatment to you. The information on or accompanying the bill may include information that identifies you, as well as the treatment you received or medications you are taking.

    We will use PHI for health care operations. Example: The Medical Center may use information in your health record to monitor the performance of a doctor, anesthesiologist or medical staff providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.

    We are likely to use or disclose PHI for the following reasons:

    Business associates: There are some services provided by us through contracts with business associates. Examples include our software system vendor and technology provider Data Strategies. When these services are contracted for, we may disclose PHI about you to our business associate so that they can perform the job we have asked them to do. Anesthesiologists, whose purpose is to provide anesthesia to you for procedures scheduled in our surgery center, will obtain information from your medical record that will be used to provide their services to you. Communication with individuals involved in your care or payment for your care: Health professionals such as doctors, anesthesiologists, nurses, medical assistants, science lab personnel (embryologists and clinical lab scientists) business office personnel and pharmacies, using their professional judgement may disclose to a family member, other relative, close personal friend or any person you identify PHI relevant to that person’s involvement in your care or payment related to your care. Public Health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury or disability. Law Enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process. Health oversight activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws. Judicial and administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI. We are permitted to use or disclose PHI about you for the following purposes: RESEARCH, CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS, SPERM DONOR, EGG DONOR OR SURROGATE PROCUREMENT ORGANIZATIONS, NOTIFICATION OF FAMILY MEMBER OR PERSONAL REPRESENTATIVE, CORRECTIONAL INSTITUTIONS, MILITARY AND VETERANS, NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES, VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE.

    Other Uses and Disclosures of PHI

    The Medical Center will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above or as otherwise permitted as required by law. You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.

    For More Information or to Report a Problem

    If you have questions or would like additional information about the Medical Center’s privacy practices you may contact the “Privacy Officer” whose name appears at the end of this notice at the Medical Center address and telephone number at the top of page 1 of this notice.

    If you believe your privacy rights have been violated, you can file a complaint with the “Privacy Officer” whose name appears at the end of this notice or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

    Effective Date

    This notice is effective as of April 14, 2003

    Privacy Officer: BETH TORRES, M.A.

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