Springboro Vision Center - Privacy Notice

Springboro Vision Center
Privacy Notice

NOTICE OF PRIVACY PRACTICES Effective date: April 14, 2003

Kara S. Hampton, O.D. Springboro Vision Center 245 N. Main St., Ste.300 (937) 748-2955 Springboro, OH 45066 Regina Payne, Privacy Officer

THIS NOTICE DESCRIBES HOW 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; examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; referring you to another doctor for eye care; 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.

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 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 donation
  • Uses or disclosures for health related research
  • Uses or disclosures to prevent a serious threat to health or safety
  • Uses or disclosures for specialized government functions, such as for the protection of 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 relating to worker?s compensation programs
  • 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. Information is also shared to family physicians, school nurses and nursing home facilities when so requested.

    APPOINTMENT REMINDERS We will call to remind you of scheduled appointments and leave a message on your answering machine or with someone who answers the phone if you are not available. We will mail you a post card to remind you that it is time to make an appointment. We may also call or write you to notify you of other treatments or services available at our office that might help you.

    USES OF YOUR NAME AND PICTURE Some of the standard practices of our office involve using your name and photograph. Some examples include: when you refer a new patient to our office, we will send you a letter thanking you for that referral of our new patient by name. If we see your photo in a local newspaper, we clip it to showcase on our ?Patient Spotlight Board?. When our young patients pick up their glasses, we take a photo of them to display in our Children?s locker area. Sometimes our young patients draw us artwork, which we display in our dispensary. This is not an all-inclusive list.

    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 the purposes of 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 shown at the beginning of this Notice.
  • Ask us to communicate with you in a confidential way, such as using a different address or phone number. We will accommodate these requests if reasonable, and if you pay us for any extra cost. To do so, send a written request to the office contact person shown at the beginning of this Notice.
  • Ask to see or get photocopies 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. By law, we are entitled to one 30 day extension if we send you a written notice. If you want to review or get photocopies of your health information, send a written request to the office contact person 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 and send the corrected information to persons known to get the wrong information. 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. By law, we have one 30 day extension if we send you a written notice. If you want us to amend your health information, send a written request including your reasons, to the office contact person 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. By law, the list will not include: disclosures for purposes of treatment, payment, or health care operations; disclosures with your authorization; incidental disclosures; disclosure required by law; and some other limited disclosures. You are entitled to one such list per year without charge. For more frequent lists, you will have to pay for them in advance. We will respond within 60 days of receiving your request, and by law have one 30 day extension if we notify you in writing. If you want a list, send a written request to the office contact person shown at the beginning of this Notice.
  • Get additional paper copies of this Notice of Privacy Practice upon request. If you want additional copies, send a written request to the office contact person 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 and have copies available in our office.

    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. If you want to complain to us, send a written complaint to the office contact person at the address shown at the beginning of this Notice.

    FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person shown at the beginning of this Notice.

    ---------------------tear here------------------------- ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I received a copy of Kara S. Hampton, O.D. ?s Notice of Privacy Practices.

    Patient name____________________________________

    Signature_____________________Date____________