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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.
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We respect our legal obligation to keep health information that
identifies you private. We are obligated by law to give you notice
of our privacy practices. This Notice describes how we protect
your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information
is for treatment, payment or health care operations. Examples
of how we use or disclose 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 have to do 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.
We routinely use your health information inside our office for
these purposes without any special permission. If we need to disclose
your health information outside of our office for these reasons,
we usually will not ask you for special written permission.
We will ask for special written permission if the situation is
outside of our normal uses of PHI for treatment, payment, and
health care operations.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use
or disclose your health information without your permission. 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” who perform health care
operations for us and who commit to respect the privacy of your
health information;
Unless you object, we will also share relevant information about
your care with your family or friends who are helping you with
your eye care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments,
or that it is time to make a routine appointment. We may also
call or write to notify you of other treatments or services available
at our office that might help you. Unless you tell us otherwise,
we will mail you an appointment reminder on a post card, and/or
leave you a reminder message on your home answering machine or
with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health
information unless you sign a written “authorization form.” The
content of an “authorization form” is determined by federal law.
Sometimes, we may initiate the authorization process if the use
or disclosure is our idea. Sometimes, you may initiate the process
if it’s your idea for us to send your information to someone else.
Typically, in this situation you will give us a properly completed
authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization
form, you do not have to sign it. If you do not sign the authorization,
we cannot make the use or disclosure. If you do sign one, you
may revoke it at any time unless we have already acted in reliance
upon it. Revocations must be in writing. Send them to the office
contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information.
You can:
· ask us to restrict our uses and disclosures for purposes of
treatment (except emergency treatment), payment or health care
operations. We do not have to agree to do this, but if we agree,
we must honor the restrictions that you want. To ask for a restriction,
send a written request to the office contact person at the address,
fax or E Mail shown at the beginning of this Notice.
· ask us to communicate with you in a confidential way, such
as by phoning you at work rather than at home, by mailing health
information to a different address, or by using E mail to your
personal E Mail address. We will accommodate these requests if
they are reasonable, and if you pay us for any extra cost. If
you want to ask for confidential communications, send a written
request to the office contact person at the address, fax or E
mail shown at the beginning of this Notice.
· ask to see or to get photocopies of your health information.
By law, there are a few limited situations in which we can refuse
to permit access or copying. For the most part, however, you will
be able to review or have a copy of your health information within
30 days of asking us (or sixty days if the information is stored
off-site). You may have to pay for photocopies in advance. If
we deny your request, we will send you a written explanation,
and instructions about how to get an impartial review of our denial
if one is legally available. By law, we can have one 30 day extension
of the time for us to give you access or photocopies if we send
you a written notice of the extension. If you want to review or
get photocopies of your health information, send a written request
to the office contact person at the address, fax or E mail shown
at the beginning of this Notice.
· ask us to amend your health information if you think that it
is incorrect or incomplete. If we agree, we will amend the information
within 60 days from when you ask us. We will send the corrected
information to persons who we know got the wrong information,
and others that you specify. If we do not agree, you can write
a statement of your position, and we will include it with your
health information along with any rebuttal statement that we may
write. Once your statement of position and/or our rebuttal is
included in your health information, we will send it along whenever
we make a permitted disclosure of your health information. By
law, we can have one 30 day extension of time to consider a request
for amendment if we notify you in writing of the extension. If
you want to ask us to amend your health information, send a written
request, including your reasons for the amendment, to the office
contact person at the address, fax or E mail shown at the beginning
of this Notice.
· get a list of the disclosures that we have made of your health
information within the past six years (or a shorter period if
you want). By law, the list will not include: disclosures for
purposes of treatment, payment or health care operations; disclosures
with your authorization; incidental disclosures; disclosures required
by law; and some other limited disclosures. You are entitled to
one such list per year without charge. If you want more frequent
lists, you will have to pay for them in advance. We will usually
respond to your request within 60 days of receiving it, but by
law we can have one 30 day extension of time if we notify you
of the extension in writing. If you want a list, send a written
request to the office contact person at the address, fax or E
mail shown at the beginning of this Notice.
· get additional paper copies of this Notice of Privacy Practices
upon request. It does not matter whether you got one electronically
or in paper form already. If you want additional paper copies,
send a written request to the office contact person at the address,
fax or E mail shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy
Practices until we choose to change it. We reserve the right to
change this notice at any time as allowed by law. If we change
this Notice, the new privacy practices will apply to your health
information that we already have as well as to such information
that we may generate in the future. If we change our Notice of
Privacy Practices, we will post the new notice in our office,
have copies available in our office, and post it on our Web site.
COMPLAINTS
If you think that we have not properly respected the privacy
of your health information, you are free to complain to us or
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 E mail shown at the
beginning of this Notice. If you prefer, you can discuss your
complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call
or visit the office contact person at the address or phone number
shown at the beginning of this Notice.
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ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of [name of O.D.’s] Notice
of Privacy Practices.
Patient name _____________________________________________________
Signature _____________________________________________ Date
__________
Effective date of notice: __________________
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