Success Vision Express and Dr. Richard Presley & Assoc.
Effective date of notice: 04/14/2003
Updated: 7/14/09 (v4.0.3)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
We respect our legal obligation to keep the health information that identifies you. 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 HEALTHCARE OPERATIONS
The most common reason we use or disclose your health information is for treatments, payment, or health care operations.
Examples of how we use or disclose information for treatment purposes are:
Setting 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.
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).
Examples of how we use or disclose your health information for functions that we have to perform to run our office are:
Financial or billing audits; internal quality assurance; personal 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 U.S. 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 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 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 the evaluation and health of members of the foreign service
- Disclosures of de-identified information
- Disclosures of a "limited data set" for research, public health, or healthcare operations
- 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.
We may call or write to remind you of scheduled appointments or that it is time to make a routine appointment. Annual correspondence typically includes an open-faced postcard with current coupons. We may also call (and leave a message, if applicable) or write to notify you of other treatments or services available at our office that might help you.
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 of 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.
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 purposes of treatment (except emergency treatment), payment, or healthcare 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 our office.
- Ask us to communicate with you confidentially, such as by phoning you at work rather than home or by mailing health information to a different 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 our office.
- 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 60 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 for us to give you access or photocopies if we send you written notice of the extension. If you want to review or get photocopies of your health information, send a written request to our office.
- 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 that 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 an amendment if we notify you of the extension in writing. If you want to ask us to amend your health information, send a written request to our office, including your reasons for the amendment.
- 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 if we notify you of the extension in writing. If you want a list, send a written request to our office.
- Get an additional paper copy of this notice of Privacy Practices upon request. It does not matter whether you got one in paper form already. If you want an additional paper copy, send a written request to our office.
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 one in our office and have copies available in our office.
If you think that we have not properly respected the privacy of your health information, you are free to complain to 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. If you prefer, you can discuss your complaint in person or by phone with the manager.