NOTICE OF PRIVACY PRACTICES

 

Effective Date: April 14, 2003

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

 

If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice.

 

Each time you visit a healthcare provider, a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information.  This Notice applies to all of the records of your care generated by your health care provider.

 

Our Responsibilities

 

Bellows, Goodman, Shaker & Siegal Medical Eye Center is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information.  The current Notice will be posted in the waiting room and will include the effective date.

 

We are required to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time.  Changes to the Notice will apply to your medical information that we already maintain as well as new information received after the change occurs.  If we change our Notice, it will be posted in the waiting room.  You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment.  This Notice will also serve to advise you as to your rights with regard to your medical information.

 

How We May Use and Disclose Medical Information About You.

 

The following categories describe examples of the way we use and disclose medical information:

 

1.      For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services.  We may disclose medical information about you to other doctors, nurses, technicians, medical students, or other personnel who are involved in your care. 

 

      We may also provide a subsequent healthcare provider with copies of various reports that              

      should assist him or her in treating you.

 

2.      For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer.  For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you.  The insurance company may use that information in connection with making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

 

3.      For Health Care Operations: We may use or disclose, as needed, your health information in order to support our business activities.  These activities may include, but are not limited to, calling you by name in the waiting room when your physician or technician is ready to see you.  We may contact you to remind you of your appointment either by phone or by mail.

 

 

4.  Business Associates: There are some services provided in our organization through contracts                

     with business associates (e.g., transcription services, radiology, laboratory tests).  When these

     services are contracted, we may disclose your health information to our business associate so

     that they can perform the job that 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 through a written contract.

 

 

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

 

We also may use and disclose your health information as set forth below.  You have the opportunity to agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then your physician may, using professional judgement, determine whether the disclosure is in your best interest.  In this case, only the information that is relevant to your health care will be disclosed.

 

1. Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may  

    release medical information about you to a friend or family member who is involved in your

    medical care or who helps to pay for your care.  In addition, we may disclose medical    

    information about you to an entity assisting in a disaster relief effort so that your family can be

    notified about your condition, status and location.

 

2. Future Communications: We may communicate to you via mailings or telephone calls    

    regarding treatment options; information on health-related benefits or services; to remind you

    that you have an upcoming appointment; to inform you of an appointment change or to assess

    your satisfaction with our services.

 

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

 

We may use or disclose your health information in the following situations without your authorization or without providing you with an opportunity to object.  These situations include:

 

1.      As required by law.  We may use and disclose health information to the following types of

Entities, including but not limited to:

 

a.       Food and Drug Administration

b.       Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability

c.       Correctional Institutions

d.       Workers Compensation Agents

e.       Organ and Tissue Donation Organizations

f.        Military Command Authorities

g.       Health Oversight Agencies

h.       Funeral Directors, Coroners and Medical Directors

i.         National Security and Intelligence Agencies

j.         Protective Services for the President and Others

k.       Authority that receives reports on abuse and neglect

 

     

2.      Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

 

3.      State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs.

 

Your Health Information Rights

 

Although your health record is the physical property of  Bellows, Goodman, Shaker & Siegal Medical Eye Center that compiled it, you have the right to:

 

1.      Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

 

2.      Amend:  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by us.  We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

 

3.      An Accounting of Disclosures: You have the right to request an accounting of our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure.

 

4.      Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a procedure that you had.

 

 

            We are not required to agree to your request.  If we do agree, we will comply with your

            Request unless the information is needed to provide you with emergency treatment.

 

5.      Request  Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  We will agree to the request to the extent that it is reasonable for us to do so.  For example, you can ask that we use an alternative address for billing purposes.

6.      A Paper Copy of This Notice: You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. 

 

To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

 

Complaints

 

If you believe your privacy rights have been violated, you may file a complaint with Bellows, Goodman, Shaker & Siegal Medical Eye Center by contacting (603) 668-2020 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services.  All complaints must be submitted in writing.

 

You will not be penalized for filing a complaint.

 

Other Uses of Medical Information

 

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you.

 

Please contact (603) 668-2020 and ask for the PRIVACY OFFICER, if you have any questions regarding this notice.

 

 

Patient Acknowledgment:

 

I acknowledge that I have received Bellows, Goodman, Shaker & Siegal Medical Eye Center’s Notice of Privacy Practices.

 

 

 

_______________________________     ___________________________   _______________

Signature of Patient or Representative        Authority or relationship of                        Date

                                                                             Representative