Effective date of notice: April 18, 2008
Eye Center South
2020 Cattlemen Rd Ste 500
Sarasota, FL 34232
Contact Persons: Helen Newman and Dr. Todd Morgan
Notice of Health Information Privacy Practices
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.
Eye Center South is committed to treating and using Protected Health Information about you responsibly. Protected Health Information is information about you, including demographic information, that may identify you and that relates to your past, present, or future physician or mental health condition and related health care services. This Notice of Health Information Privacy Practices describes the Protected Health Information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective March 31, 2008.
Understanding Your Health Record/Information
Each time you visit Eye Center South, a record of your visit is made and maintained in your medical record. Typically, this record contains the physician office notes, test results and plan of treatment. We also maintain a record of your billing and payment history. This information, often referred to as your health or medical record, serves as a:
° Basis for planning your care and treatment,
° Means of communication among the many health professionals who contribute to your care,
° Legal document describing the care you received,
° Means by which you or a third-party payer can verify that services billed were actually provided,
° A tool in educating heath professionals,
° A source of data for medical research
° A source of information for public health officials charged with improving the health of this state and the nation,
° A source of data for our planning and marketing,
° A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve,
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of Eye Center South, the information belongs to you. You have the right 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, or fax 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, or fax 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, or fax 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, or fax 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, or fax 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, or fax shown at the beginning of this Notice.
Eye Center South is required to:
° Maintain the privacy of your health information,
° Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,
° Abide by the terms of this notice,
° Notify you if we are unable to agree to a requested restriction, and
° Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
If we change our information practices in such a way that the information in this Notice is no longer accurate, we will post a copy of the updated Notice in our office and will offer you an updated copy on your first visit following the change.
We will not use or disclose your health information without your authorization, except as described in this notice.
For More Information or to Report a Problem
If you have questions or complaints about our Privacy Practices, or if you would like additional information, you may contact the practice’s Privacy Officer, at (941) 378-3937. You may also file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is:
Office for Civil Rights
Atlanta Federal Center
61 Forsyth Street
Atlanta, GA 30303-8907
Phone Number (404)562-7886 Fax Number (404)562-7881 TDD line (404)331-2867
Examples of Disclosures for Treatment, Payment and Healthcare Operations
We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. We will also provide any specialist you might be referred to with copies of various reports that should assist him or her in treating you.
We will use your health information for payment. For example: A bill may be sent to you or to a third party responsible for payment.
We will use your health information for healthcare operations. For example: We will use your information to assess the quality of the care provided to you.
Examples of Other Uses and Disclosures
Business associates: There are some services provided in our organization through contracts with people or organizations which provide services to us. These people are our business associates. Examples include our copy service or the company transcribing dictation for us. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.. If you object to this, please let us know. If you are unable to object, we may disclose such information as we deem necessary for your best interest based on our professional judgment.
Communication with family: We may disclose your health information to a family member, other relative, close personal friend or any other person you identify as participating in your care. We will disclose only that health information relevant to that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Funeral directors, coroners, and medical examiners: We may disclose health information to funeral directors consistent with applicable law to carry out their duties. We may also disclose health information to a coroner or medical examiner to identify a deceased person or determine the cause of death.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Appointment Reminders, Treatment Alternative, and Health-Related Benefits: We may use your health information to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you do not want us to contact about these things, please notify our Privacy Officer in writing of your wishes.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs.
Public health: As required by law, we may disclose your health information to public health or legal authorities including to prevent or control disease, injury, or disability, to report child or elder abuse or neglect, and to report reactions to medications
Health Oversight Activities: We may disclose your information to oversight agencies, such as government agencies, who conduct audits, investigations, and inspections regarding health benefit programs, the health care system, and civil rights.
Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or law enforcement agents holding you in custody, health information necessary for your health and safety and the health and safety of other individuals and the institution.
Law enforcement: We may disclose health information for law enforcement purposes as required by law.
Legal Proceedings: We may disclose your health information in the course of a judicial or administrative proceeding as required or allowed by law.
Disaster Relief Efforts: We may use or disclose your health information to an authorized disaster relief organization to coordinate and assist with disaster relief efforts.
Military and National Security: We may disclose your health information to authorized federal officials, including officials of the Armed Forces, for conduction military, national security, or intelligence activities.
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Eye Center South’s Notice of Privacy Practices.
Patient name _____________________________________________________
Signature ___________________________________Date _______