COVINGTON OPTOMETRIC EYE CLINIC
Privacy Practice Notice
PO Box 2020; 101 Medical Circle Drive; Rockingham, NC 28379 PH: (910) 997-4489 Fax: (910) 895-7453
310 N. Greene St.; Wadesboro, North Carolina 28170 PH: (704) 694-6799 Fax: (704) 694-9827
703 Market St.; Cheraw, South Carolina 29520 PH: (843) 537-3641 Fax: (843) 537-3646
Last Revision: October 18, 2013
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.
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 admin. 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 eval. 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 for us and who commit to respect the privacy of your health information;
Unless you object, we will also share relevant info about your eye care with your family or friends who assist you with your eye care.
APPOINTMENT REMINDERS: We need 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 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.
SPECIFIC USES AND DISCLOSURES OF INFORMATIONREQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosures we may not make of your health information without your authorization:
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 may take 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 health 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 TO PROVIDE AN AUTHORIZATION FOR 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 will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.
* 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 I 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 another person other than the health plan has paid in full on your behalf.)
Any authorization that you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time you decide. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, 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.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have many rights concerning the confidentiality of your health info. You have the right:
1. To 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.
2. To 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.
3. To inspect or copy your health information. You must make such requests in writing to the address listed on this document. If you request a copy of your health records we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your requests to inspect or copy your health information, subject to applicable law.
4. To amend your health information. If you feel that the health information that we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address on this document. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information:
o Was not created by us, unless the person that created the information is no longer available to make the amendment.
o Is not part of the health information kept by or for us.
o Is not part of the information you would be permitted to inspect or copy, or
o Is accurate and complete.
5. To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper or electronically).
6. 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 health information directly to another person the requests must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.
Abbie Prevatt is our contact person for all questions, requests or for further information related to the privacy of your health information.
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.
Changes to this Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revision Notice that will be posted prominently in our facility. Copies of this Notice are available upon requests at our reception area.
Notice Revised and Effective: October 18, 2013
Acknowledgement of Receipt
Patients in our practices will be acknowledging that they have received or have been offered a copy of our privacy practices by way of applying their signature to the welcome information sheet given to, completed by and kept on record for all new patients, as well as, updated every 2-3 years by all established patients.
Patients in our practices are also able to designate on the welcome information sheet which is given to, completed by and kept on record for all new patients, as well as, updated every 2-3 years by all established patients, the name, relationship and contact number for up to two (2) persons. By giving this information to us the patient allows us to give to those persons personal health information regarding themselves in any of the following formats: written, verbal or copied. We will keep those designated persons applicable for receipt of information until such time that the patient updates the form or removes their names. The patient has the ability to change this form and those designated names at any time they wish.