OUR LEGAL OBLIGATION
We respect applicable federal and state law to maintain the privacy of your health information. We are also obligated to give you this Notice about our legal duties and privacy practices, and your rights concerning your health information. We must abide by the privacy practices that are described in this Notice while it is in effect and until such time that we choose to change it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. If we change our privacy practices and the terms of this Notice, we reserve the right to apply the new practices and new terms of the Notice for all health information created or received before we made the changes. At the time we make a material change in our privacy practices, we will post a revised notice. Additionally, you may request a copy of the revised notice at any time.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
During the ordinary course of providing treatment and health care services to you, you will provide us with personal information such as, but not limited to:
- Name, mailing address and contact information (e.g. phone, fax, email address)
- Your medical history
- Insurance and coverage information
- Names and contact information of your other health care providers
In addition to the information provided by you, we will gather health care information about you create a record of care provided to you by our practice.
We use and disclose health information about you for treatment, payment and health care operations, as indicated below. Additional uses and disclosure of health information is provided in the following examples:
Treatment: We may use and disclose your health information in your treatment. For example, we will use your health information, including your medical history, to access the health of your eyes, to perform an eye examination, to prescribe vision correction devices such as eyeglasses or contact lenses, and/or to prescribe medications. We may also disclose your health information to a physician or other healthcare provider providing treatment to you. We may also receive your health information from another health care provider that you have seen at on prior occasions.
Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may need to provide information about your medical conditions to your insurance company in order to determine the extent to which services are covered by your insurance and/or to collect payment for our services.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include administrative and managerial functions that are necessary in the general operations of our practice. We may use or disclose your health information to consultants or auditors that provide quality assessment and reviews of our service activities.
Your Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose in addition to our use and disclosure of your health information for treatment, payment or healthcare operations. You may revoke this authorization in writing at any time, however, your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We cannot use or disclose your health information for any reason except those described in this Notice unless you provide us a written authorization.
Family and Friends: We may disclose your health information to individuals involved in your care, or in the payment of your care, including a family member, friend or other person to the extent necessary. Generally we will do so only if you verbally agree that we may do so, however, under certain circumstances such as in an emergency, we may use and disclose health information without your agreement.
Appointment Reminders: We may use or disclose your health information to provide you with a reminder that you have an appointment or to schedule an appointment. We may also contact you in order to follow up on treatment plans or other services. Such contact may include, but are not limited to, telephone calls, voicemail messages, postcards, e-mails or letters. You may elect not to receive such reminders and we will respect your requests.
Health-Related Business Associates & Other Services: We may disclose your health information to business associates and service provides that we hire to help us operate our practice more successfully when disclosure of such information is required in order to perform the tasks we have hired them to complete. We may disclose your health information for the purpose of advising you about possible treatment options, alternatives or other health related services that may be of interest to you. We will secure from these business associates and/or other service providers a promise that they will respect the confidential nature of any health information we provide about you.
Required by Law / Public Health: We may use or disclose your health information when we are required to do so by law (Federal, State or Local), including in response to a subpoena, warrant, or other court order. We may disclose your health information to the Food and Drug Administration (FDA) for various reasons, for example, to report adverse events, product defects or problems, to facilitate product recalls and to conduct post marketing surveillance. We may disclose your health information in connection with public health reporting activities, including, for example, the request of public health authorities authorized to collect your health information for the purpose of preventing or controlling disease. Examples of public health authorities include, but are not limited to, the following; state health departments, the Center for Disease Control, the Food and Drug Administration, and the Occupational Safety and Health administration. We may disclose your health information to authorized federal officials when required for lawful intelligence, counterintelligence, and other national security activities. We may disclose your health information to a correctional institution or law enforcement official having lawful custody of an inmate or patient under certain circumstances.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
WebSite: If you view our website or complete forms on our website, certain information including domain name, IP addresses may be collected in the course of your visit. Such information is used only in aggregate statistical format to help us make our web site more useful. No individual or personal identifiable information is permanently stored other than what you may specifically provide (e.g. an email address). Our web site may use “cookies” i.e. a piece of data stored on the user’s computer. Usage of a cookie is not linked to any personally identifiable information on our web site. All cookies on our website are terminated once the user closers their web browser. Visitors to our website may be linked to the other websites, including those of business associates and service providers we use. We are not responsible for any information collected by any website linked from our website nor do the rights and obligations, nor the policies regarding the use and disclosure of your health information indicated in this Notice apply.
Access: You have the right to view or attain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. We have the right to charge an administrative cost-based fee for the preparation of the information you request to cover staff time and other incidental expenses incurred in the fulfillment of your request.
Restriction: You have the right to request that we restrict our use or disclosure of your health information. We are not, however, required to agree to these additional restrictions. In the case that we do agree, we will abide by our agreement (except in an emergency). Restrictions must be made by a written request to the office contact person indicated at the bottom of this notice.
Disclosure Accounting: You have the right to receive a list of instances in which we have disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request the accounting more than once in a 12 month period, we may charge you a reasonable administrative cost-based fee for responding to these additional requests.
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location and must be made by a written request to the office contact person indicated at the bottom of this notice.
Amendment: You have the right to request that we amend your health information, for example, to add missing information or correct existing information. Your request must be made by a written request to the office contact person indicated at the bottom of this notice and explain why the information should be amended. Under certain circumstances we may deny your request.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in paper form. You may request a copy at any time.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C., 20201 or via e-mail to firstname.lastname@example.org.
If you want more information about our privacy practices or have question or concerns, please contact us.