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NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR
HEALTH
INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT
CAREFULLY. Your
"health information," for purposes of this Notice, is generally any information that identifies
you and
is created, received, maintained or transmitted by us in the course of providing health
care items or services to you
(referred to as "health information" in this Notice).
We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA")
and other applicable laws
to maintain the privacy of your health information, to provide
individuals with this Notice of our legal duties and privacy
practices with respect to such
information, and to abide by the terms of this Notice. We are also required by law to notify
affected individuals following a breach of their unsecured health information.
USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION
The most common reasons why we use or disclose your health information are for treatment,
payment or health care
operations. Examples of how we use or disclose your health information
for treatment purposes are: setting up an
appointment for you; testing or examining your eyes;
prescribing glasses, contact lenses, or eye medications and faxing
them to be filled; showing
you low vision aids; referring you to another doctor or clinic for eye care or low vision aids
or
services; or getting copies of your health information from another professional that you may
have seen before us.
Examples of how we use or disclose your health information for payment
purposes are: asking you about your health or
vision care plans, or other sources of payment;
preparing and sending bills or claims; and collecting unpaid amounts
(either ourselves or
through a collection agency or attorney). "Health care operations" mean those administrative and
managerial functions that we must carry out in order to run our office. Examples of how we use
or disclose your health
information for health care operations are: financial or billing audits;
internal quality assurance; personnel decisions;
participation in managed care plans; defense of
legal matters; business planning; and outside storage of our records.
OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT
In some limited situations, the law allows or requires us to use or disclose your health
information without your consent
or authorization. Not all of these situations will apply to
us; some may never come up at our office at all. Such uses or
disclosures are:
* When a state or federal law mandates that certain health information be reported for a
specific purpose;
* For public health purposes, such as contagious disease reporting, investigation or
surveillance; and notices to and from
the federal Food and Drug Administration regarding drugs or
medical devices;
* Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic
violence;
* Uses and disclosures for health oversight activities, such as for the licensing of doctors; for
audits by Medicare or
Medicaid; or for investigation of possible violations
of health care laws;
* Disclosures for judicial and administrative proceedings, such as in response to subpoenas or
orders of courts or
administrative agencies;
* Disclosures for law enforcement purposes, such as to provide information about someone who is
or is suspected to be a
victim of a crime; to provide information about a
crime at our office; or to report a crime that happened somewhere else;
* Disclosure to a medical examiner to identify a dead person or to determine the cause of death;
or to funeral directors to
aid in burial; or to organizations that handle
organ or tissue donations;
* Uses or disclosures for health related research;
* Uses and disclosures to prevent a serious threat to health or safety;
* Uses or disclosures for specialized government functions, such as for the protection of the
president or high ranking
government officials; for lawful national intelligence activities; for
military purposes; or for the evaluation and health
of members of the
foreign service;
* Disclosures of de-identified information;
* Disclosures relating to worker's compensation programs;
* Disclosures of a "limited data set" for research, public health, or health care operations;
* Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
* Disclosures to "business associates" and their subcontractors who perform health care
operations for us and who
commit to respect the privacy of your health information in accordance
with HIPAA;
Unless you object, we will also share relevant information about your care with any of
your personal representatives who
are helping you with your eye care. Upon your death, we may
disclose to your family members or to other persons who
were involved in your care or payment
for heath care prior to your death (such as your personal representative) health
information
relevant to their involvement in your care unless doing so is inconsistent with your preferences
as expressed
to us prior to your death.
SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosures we may not make of your health information
without your
authorization:
Marketing activities: We must obtain your authorization prior to using or disclosing any
of your health information for
marketing purposes unless such marketing communications take the
form of face-to-face communications we may make
with individuals or promotional gifts of nominal
value that we may provide. If such marketing involves financial payment
to us from a third party
your authorization must also include consent to such payment.
Sale of health information: We do not currently sell or plan to sell your health
information and we must seek your
authorization prior to doing so.
Psychotherapy notes: Although we do not create or maintain psychotherapy notes on our patients,
we are required to
notify you that we generally must obtain your authorization prior to using or
disclosing any such notes.
YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES
* Other uses and disclosures of your health information that are not described in this Notice
will be made only with
your written authorization.
* You may give us written authorization permitting us to use your health information or to
disclose it to anyone for any
purpose.
* We will obtain your written authorization for uses and disclosures of your health information
that are not identified in
this Notice or are not otherwise permitted by
applicable law.
* We must agree to your request to restrict disclosure of your health information to a health
plan if the disclosure is for the
purpose of carrying out payment or health care operations and
is not otherwise required by law and such information
pertains solely to a health care item or
service for which you have paid in full (or for which another person other than
the health plan
has paid in full on your behalf).
Any authorization you provide to us regarding the use and disclosure of your health information
may be revoked by you
in writing at any time. After you revoke your authorization, we will no
longer use or disclose your health information for
the reasons described in the authorization.
However, we are generally unable to retract any disclosures that we may have
already made with
your authorization. We may also be required to disclose health information as necessary for
purposes
of payment for services received by you prior to the date you revoked your authorization.
YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
* To request restrictions on the health information we may use and disclose for treatment,
payment and health care
operations. We are not required to agree to these requests. To request
restrictions, please send a written request to us at
the address below.
* To receive confidential communications of health information about you in any manner other than
described in our
authorization request form. You must make such requests in writing to the address
below. However, we reserve the right
to determine if we will be able to continue your treatment
under such restrictive authorizations.
* To inspect or copy your health information. You must make such requests in writing to the
address below. If you request
a copy of your health information we may charge you a fee for the
cost of copying, mailing or other supplies. In certain
circumstances we may deny your request to
inspect or copy your health information, subject to applicable law.
* To amend health information. If you feel that health information we have about you is incorrect
or incomplete, you may
ask us to amend the information. To request an amendment, you must write to
us at the address below. You must also
give us a reason to support your request. We may deny your
request to amend your health information if it is not in
writing or does not provide a reason to
support your request. We may also deny your request if the health information:
- was not created by us, unless the person that created the information is no longer
available to make the amendment
- is not part of the health information kept by or for us,
- is not part of the information you would be permitted to inspect or copy, or
- is accurate and complete.
* To receive an accounting of disclosures of your health information. You must make such requests
in writing to the
address below. Not all health information is subject to this request. Your
request must state a time period for the
information you would like to receive, no longer than 6
years prior to the date of your request and may not include dates
before April 14, 2003. Your
request must state how you would like to receive the report (paper, electronically).
* To designate another party to receive your health information. If your request for access of
your health information
directs us to transmit a copy of the health information directly to
another person the request must be made by you in
writing to the address below and must clearly
identify the designated recipient and where to send the copy of the health
information.
Complaints:
If you think that we have not properly respected the privacy of your health information, you are
free to complain to us or
to the U.S. Department of Health and Human Services, Office for Civil
Rights. We will not retaliate against you if you
make a complaint. If you want to complain to us,
send a written complaint to the office contact person at the address, fax
or email shown above.
If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health
information about you
that we already have. Any revision to our privacy practices will be
described in a revised Notice that will be posted
prominently in our facility. Copies of this
Notice are also available upon request at our reception area.
ACKNOWLEDGEMENT OF RECEIPT
I have been given the opportunity to read this practice's HIPPA Privacy Policies.*