This Notice of Privacy Practices describes how Boca Fertility may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your “protected health information”. PHI is information about you, that may identify you and that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN CONSENT

You will be asked to sign a consent form after reviewing this notice. Once you have consented to use and disclosure of your PHI for treatment, payment and health care operations by signing the consent form, we at Boca Fertility will use or disclose your protected health information as described. Your PHI may be used and disclosed by Dr. Peress, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills. We will not use or disclose your health information without your authorization, except as described in this notice.

Following are examples of the types of uses and disclosures of your protected health care information that we at Boca Fertility are permitted to make once you have signed our consent form.

TREATMENT: We will use and disclose your PHI to provide, coordinate or manage your health care and any related services.

For Example: Information obtained by Dr. Peress, a nurse or other members of our staff will be recorded in your chart and will be used to determine the course of treatment. Our staff will record their observations and actions taken. This will allow Dr. Peress to know how you are responding to treatment.

We will also disclose PHI to other physicians or a subsequent healthcare providers that will assist them in treating you once you are discharged from this practice.

For Example: Your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for health care services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

For Example: Obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission. Also, a bill may be sent to you or a third party payer with information that identifies you, as well as your diagnosis, procedures and supplies used.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to improve the quality and effectiveness of the healthcare and reproductive medicine services we provide.

For Example: We may disclose your PHI to medical or nursing school students that see patients in our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your PHI as necessary, to contact you of your appointment.

Business Associates: There are some services provided at Boca Fertility through contacts with business associates. For Example: We will share your protected health information with third party “business associates” that perform various activities (i.e., billing, transcription services) for the practice, including certain laboratory tests and the services of anesthesiologists and psychologists. When these services are used, we may disclose your PHI to our business associate so they can perform the job we have asked them to do. Your health information is protected through our agreement with our business associates to appropriately safeguard your information. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your protected health information.We will collect health information on you and your spouse/significant other.

For Example: Although health information in your medical record belongs to you, it will contain some information pertaining to your spouse/significant other. This is because the treatment of infertility may focus on the couple, rather than the individual.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATON

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing by certified mail, except to the extent that Dr. Peress or Boca Fertility has taken an action in reliance on the use or disclosure indication in the authorization.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT

We may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the PHI, that Dr. Peress may, using professional judgement, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

COMMUNICATION WITH SPOUSE/FAMILY: Health professionals, using their best judgment, at your request, may disclose to your spouse, family member, or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. We will give you an opportunity to revoke your decision in writing at any time.

EMERGENCIES: We may use or disclose your PHI in an emergency treatment situation. If this happens, Dr. Peress shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If Dr. Peress is required by law to treat you and has attempted to obtain your consent but is unable to obtain your consent, we may still use or disclose your protected health information to treat you.

COMMUNICATION BARRIERS: We may use and disclose your PHI if Dr. Peress or his staff attempts to obtain consent from you but is unable to do so due to substantial communication barriers and Dr. Peress determines, using professional judgement, that you intend to consent, to use or disclosure under the circumstances.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT

We may use or disclose your PHI in the following situations without your consent or authorization. These situations include:

REQUIRED BY LAW: We may use or disclose your protected health information to the extent that the use or disclosure is required by law or in response to a valid subpoena, discovery request or other lawful process. The use or disclosure will be made in compliance with the law and your health information will be released to an appropriate public health authority or attorney and will be limited to the relevant requirements of the law.

PUBLIC HEALTH: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. Data from your assisted reproductive technology (ART) procedure will also be provided to the Centers for Disease Control and Prevention (CDC). The 1992 Fertility Clinics Success Rate and Certification Act requires that the CDC collect data on all ART data. Because sensitive information will be collected on you, the CDC applied for and received an “assurance of confidentiality” for this project under the provisions of the Public Health Service Act, Section 308 (d). This means that any information that the CDC has that identifies you will not be disclosed to anyone else without your authorization.

RESEARCH: We may disclose information to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. In most cases, we will de-identify your patient information so that others can use the de-identified information to study reproductive health care and health care delivery without learning who you are.

FOOD AND DRUG ADMINISTRATION (FDA): We may disclose your PHI to a person or company required by the FDA to report adverse events, product defects or problems, biologic product deviations, track products, to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

REQUIRED USES AND DISCLOSURES: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq..

YOUR RIGHTS

• You have the right to inspect and copy your protected health information.
• You have the right to request a restriction of your protected health information.
• You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
• You may have the right to have your physician amend your protected health information.
• You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
• You have the right to obtain a paper copy of this notice from us, upon request.

COMPLAINTS

If you believe your privacy rights have been violated you may file a complaint to us or to the U.S. Department of Health & Human Services: Office of Civil Rights, 200 Independence Ave., S.W., Washington, DC 20201. You may file a complaint with us by notifying our office. We will not retaliate against you for filing a complaint.

You may contact our office for further information about the complaint process. You may contact Missy at Toll Free 1.844.773.3855 This notice is effective as of April 14, 2003