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 plans, or to other sources of payment; preparing and
sending bills or claims; and collection 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 manager care plans; defense or 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 in the following
situations:________________________.]
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
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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:
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When a state or federal law mandates that certain health information be reported
for a specific purpose;
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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;
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Disclosures to governmental authorities about victims of suspected abuse,
neglect or domestic violence;
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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;
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Disclosures for judicial and administrative proceedings, such as in response
to subpoenas or orders of courts or administrative agencies;
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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;
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Disclose to a medical examiner to identify a dead person or to determine
the cause of death; or to funeral director to aid in burial; or to organizations
that handle organ or tissue donations;
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Uses or disclosures for health related research;
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Uses and disclosures to prevent a serious threat to health or safety;
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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 services;
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Disclosures of de-identifies information;
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Disclosures of a "limited data set" for research, public health, or health
care operations;
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Disclosures relating to worker's compensation programs;
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Disclosures that are an unavoidable by-product of permitted uses or disclosures;
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Disclosures to "business associates" who perform health care operations for
use and who commit to respect the privacy of your health information:
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[Specify other uses and disclosures affected by state law].
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 scheduling 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:
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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.
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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.
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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 with in 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 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.
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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 the persons
who we know got the wrong information, and others that you specify. If we
do not agree, you can write a statement of position and/or 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, 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.
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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 of
health care operations; disclosure 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 requests 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.
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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 observe 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 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 our office contact person at the address, fax or E-Mail shown
at the beginning of this Notice. If you prefer, you can dismiss 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.
I acknowledge that I have reviewed a copy of Allen Vision Center's Notice
of Privacy Practices.
Signature: ______________________________ Date: _____/______/ 20______
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