Notice of Privacy Practices
Privacy officer: Mary Anne Peck, OD
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 or payment. Examples of how we use your 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; referring you to another doctor or clinic for eye care; getting copies of your health information from another professional that you may have seen before us. Examples of 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 include: 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.
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 court orders;
• To avert a serious threat to public safety
• As required by their military command authorities for their medical records;
• To workers compensation or similar programs for processing claims
• In response to legal proceedings
• To a coroner or medical examination for identification of a body
• If an inmate, to the correctional institution or law enforcement official
• Other healthcare providers’ treatment activities
We may contact you to provide appointment reminders or information about treatment alternative or other health related benefits.
Uses and disclosures of protected health information requiring your written authorization
Other uses and disclosures of medical information not covered in this notice or the laws that apply to us will be made only with your written authorization. If you give authorization or disclose medical information about you, you may revoke that authorization in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care we provided you.
Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must submit your request in writing to the privacy officer of this practice. In your request, you must tell us what information you want limited.
Right to Request Confidential Communications
You have the right to request how we should send communications to you about medical matters, and where you would like those communications sent. To request confidential communications, you must make your request to the Privacy Officer at this practice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.
Right to Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records but does not include psychotherapy notes: information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at this practice. If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by this practice will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may deny your request if the information was not created by us, is not part of the medical information kept at this practice, is not part of the medical information which you were be permitted to inspect and copy, or which we deem to be accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized request for information pertaining to the appropriate portion of your record.
Right to an Accounting of Non-Standard Disclosures
You have the right to request a list of the disclosures we made of medical information about you. To request this list, you must submit your request to the Privacy Officer at this practice. Your request must state the time period for which you want to receive a list of disclosures that is not longer than six years, and may not include dates before April 14, 2003. Your request should indicate in what form you want the list, (Example: on paper or electronically). The first list you request within a 12-Month period will be free. For additional lists, we reserve the right to charge you the cost of providing the list.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at this practice.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice with the effective date in the upper right corner of this page.
Download/view Notice of Privacy Practices PDF