HIPAA Form

HIPAA Form
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By signing below, I acknowledge that a copy of Professional VisionCare's Notice of Privacy Practices was presented to me at my visit today. I also acknowledge that I understand Professional VisionCare's Privacy Practices are compliant with all applicable HIPAA and Privacy laws regarding my Protected Health Information.

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Effective date of notice: August 2, 2013

NOTICE OF PRIVACY PRACTICES

Professional VisionCare, LLC

Privacy Officer: Raquel Miller

Review Officer: Dr. Carole R. Burns, OD.

Security Officer: Anita Gardner

Public Information Officer: Raquel Miller

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOu MAY BE USED AND DISCLOSED AND HOW YOU CAN obtain 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 will ask you for special written permission when required by the Privacy Rules.

Unless you instruct us otherwise, we will create one financial account for your immediate family (eg: husband, wife and any children in your household under the age of 18 years old). Any correspondence about this account will be sent to the Responsible Party named on the account.

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 deceased 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;

·          in the case of your death, disclosures of your health information to your family members or others who were involved in your health care prior to your death, unless doing so is inconsistent with your preferences as expressed to us prior.

              Unless you object, we will also share relevant information about your care (including appointment information, access to prescriptions, and similar records requests) with your family or friends who are helping you with your eye care. If you would like to object to your family having access to your Protected Health Information, please contact the Public Information Officer, listed at the beginning of this notice.

office communication

We may call, write, email, or text to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call, write, text, or email 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 the phone number you have listed with us or with someone who answers your phone if you are not present. If you would like to restrict how we communicate with you to a particular mode of communication, please contact the Public Information Officer, listed at the beginning of this notice.

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 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 an other 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. 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.

specific uses and disclosures of information requiring your authorization

The following are some specific uses and disclosures we MUST have your authorization to complete:

·          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 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 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 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 Public Information Officer 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 your request may incur. If you want to ask for confidential communications, send a written request to the Public Information Officer at the address, fax or E-mail shown at the beginning of this Notice. We reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.

•       ask to see or to get copies 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. 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 Public Information Officer 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 30 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. We may also deny your request if the health information: 1) was not created by us, 2) is not part of the health information kept by or for us, 3) is not part of the information you would be permitted to inspect or copy, or 4) is accurate and complete. 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 Public Information Officer 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; we may charge a fee for additional lists. We will usually respond to your request within 30 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 Public Information Officer at the address, fax or E mail shown at the beginning of this Notice.

•       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 by way of our Medical Release Form, or containing all information that is required on our Medical Release form, to the Public Information Officer 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 Public Information Officer 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.

If for any reason we use or disclose your protected health information in such a way that is not permissible by law, or does not follow the requirements outlined in this Notice, we are legally obligated to notify you of the security breach and/or misuse of your protected 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 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 Public Information Officer 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

For more information about our privacy practices, call or visit the Public Information Officer at the address or phone number shown at the beginning of this Notice.
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