Effective date of notice:
NOTICE OF PRIVACY PRACTICES
_______________________________________________________________________
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.
_______________________________________________________________________
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 Dr. Mohon ’s Notice of Privacy Practices.
Patient name
_____________________________________________________
Signature
_____________________________________________ Date __________
Effective date of
notice: __________________