This notice describes how medical information about you may be used and disclosed and how you can get access to the information. Please review it carefully.
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 Healthcare Operations
The most common reason why we use or disclosure health information is for treatment, payment or healthcare operations. Examples of how we use or disclose information for your 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 disclosure health information for payment purposes are: asking you about your health or vision care plans, or other sources of payments; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Healthcare operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclosure health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense or 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 health information outside of our office for these reasons, [we will] [we usually will not] ask you for special written permission.
Uses and disclosures for other reasons without permission
In some limited situations, the law allows or requires us to use or disclosure health information without your permission. All the situations will apply to us; some may never come up in our office at all. Such uses were disclosures are:
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.
We may call or write to remind you of schedule appointments, or that it's time to make a routine appointment. We may also call or write to notify you of other treatments or services available on our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave a reminder message on your home answer machine or someone who answers your phone if you are not at home.
Other Uses And Disclosures
We will not make any uses or disclosures of the 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 we the use or disclose 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 and less 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 healthcare operations. We do not have to agree to do this, but if we agree, we may 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 few limited situations in which we can refuse to permit access or copying. For the most part, however, you'll be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off site). You may have to pay for photocopies in advance. If we deny requests, 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 have one 30 day extension of time for us to give you access or photocopies if we send you a written notice of the extension. If you want 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 information within 60 days from when you asked us. We will send the corrected information to the 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 an amendment, to the office contact 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 shorter 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 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 his 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.
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the US 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.