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Effective
date of notice: April 18, 2008
Eye
Center South
941-378-3937
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.
Introduction
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.
Our
Responsibilities
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
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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.
852518_1.doc
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ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Eye Center South’s
Notice of Privacy Practices.
Patient name _____________________________________________________
Signature ___________________________________Date _______
Eye Center South - 2020 Cattlemen Rd - Suite
500 - Sarasota, Florida 34232 - (941) 378-EYES (3937)
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