NOTICE OF PRIVACY PRACTICES

Retina Physicians & Surgeons, Inc.

 

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.

 

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.  Protected health information means health information, including demographic information, collected from me and created or received by my physician, another health care provider, health plan, my employer or a health care clearinghouse.  This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

 

You will be asked by your physician or physician's staff to acknowledge with your initials or signature that you received this Notice of Privacy Practices. We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we may obtain at that time.  Upon your request, we will provide you with any revised notice of privacy practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

 

1.         Uses and Disclosures of Protected Health Information.

 

We will use or disclose protected health information for the following purposes:

 

Treatment.  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians who may be treating you.  For example, your protected health information may be provided to a physician to whom you have been referred.

 

Payment.  Your protected health information will be used to obtain payment for your health care services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for your health care services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for an office procedure or a hospital stay may require that your protected health information be disclosed to the health plan to obtain approval for the procedure or hospital admission.

 

Health Care Operations.  We may use or disclose your protected health information in order to support the business activities of the practice.  These activities include, but are not limited to, the day-to-day running of the practice, quality assessments, employee reviews, training of medical students, licensing, marketing, and fundraising, and conducting or arranging for other business activities.

 

For example, we may disclose your protected health information to medical school students who see patients at our office.  In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician.  We may also call you by name in the waiting room when your physician is ready to see you.  We may contact you to remind you of your appointment.

 

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

 

We may use or disclose your protected health information to provide you with information about treatment, alternatives or other health-related benefits and services that may be of interest to you.  We may also use and disclose your protected health information for other marketing activities.  For example, your name and address may be used to send you a newsletter about our practice and the services we offer.  We may also send you information about products and services that we believe may be beneficial to you.  You may contact our privacy contact to request that these materials not be sent to you.

 

 

2.         Uses and Disclosures of Protected Health Information Based Upon your Written Authorization.

 

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

 

3.         Other Permitted and Required Uses and Disclosures that may be made without your Authorization or Opportunity to Object.

 

We may use or disclose protected health information in these following situations without your authorization.  These situations include:

 

Required by Law:  We may use and disclose your protected health information if the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law.

 

Public Health:  We may disclose your protected health information to public health authorities for purposes related to controlling disease, injury or disability.  This includes:

 

·        Communicable Diseases:  We may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

 

·        Health Oversight:  We may disclose your protected health information for activities such as audits, investigations and inspections by government oversight agencies.

 

·        Abuse or Neglect:  We may disclose your protected health information to report child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence.

 

Food and Drug Administration:  We may disclose your protected health information to report adverse events and product defects or problems; to enable product recalls; or to make repairs or replacements.

 

Legal Proceedings:  We may disclose your protected health information in the course of any judicial or administrative proceeding.

 

Law Enforcement:  We may also disclose protected health information to a law enforcement official for purposes such as legal proceedings; request for identification and location of a suspect, fugitive, material witness or missing person; pertaining to victims of a crime; suspicion that death has occurred as a result of criminal conduct; that a crime has occurred on the premises of the practice; and medical emergency (not on the practice’s premises) and it is likely that a crime has occurred.

 

Coroners and Funeral Directors:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties.  We may also disclose protected health information to a funeral director, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death. 

 

Organ Donation:  We may disclose protected health information to organizations involved in organ and tissue donation and transplant.

 

Research:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and establish protocols to insure the privacy of your protected health information.

 

Criminal Activity:  We may disclose protected health information, if we believe that the use of disclosure is necessary to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.

 

Military Activity and National Security:  We may use or disclose your protected health information to individuals who are armed forces personnel for activities deemed necessary by appropriate military command authorities, or for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits.  We may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

 

Workers’ Compensation:  Your protected health information may be disclosed by us as authorized to comply with Workers’ Compensation laws and other similar legally-established programs.

 

Correctional Facilities:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

 

4.         Others Involved in your Health Care.

 

Care Givers:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. We may disclose protected health information to an authorized public or private entity to assist in disaster relief efforts.

 

Emergencies.  We may use or disclose your protected health information in an emergency situation. If this happens, your physician shall try to obtain your consent as soon as possible after the emergency.

 

5.         Your Health Information Rights. 

 

You have the Right to Inspect and Copy your Protected Health Information:  This means you may inspect and obtain a copy of protected health information about you for as long as we maintain the protected health information.

 

Under federal law, there may be instances where you may not inspect or copy your protected health information.  Depending on the circumstances, a decision to deny access may be reviewable. Please contact our privacy contact if you have any questions about access to your protected health information.

 

You have the Right to Request a Restriction of your Protected Health Information:  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.

 

Your Physicians is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind please discuss any restriction you wish to request with your physician.

 

You have the Right to Request to Receive Confidential Communications from us by Alternative means or at an Alternative Location:  We will accommodate reasonable requests.  Please make this request in writing to our privacy contact.

 

You may have the right to request your physician to amend your protected health information:  This means you may request to have your protected health information changed for as long as we maintain this information.  In certain cases, we may deny your request to have your protected health information changed.  If we deny your request for a change, you have the right to disagree with us. Please contact our privacy contact if you have questions about making changes to your protected health information and how you can disagree with our decision.

 

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information:  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you, family members or friends involved in your care or for notification purposes.  It excludes disclosures made pursuant to a valid authorization.  The right to receive this information is subject to certain exceptions, restrictions and limitations.

 

You have the right to obtain a paper copy of this notice from us: If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our privacy contact.

 

6.            Complaints

 

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.  We will not retaliate against you for filing a complaint.

 

You may contact our Privacy Officer at 937-427-8900 for further information about the complaint process.

 

7.            Change of Ownership

 

In the event that Retina Physicians & Surgeons, Inc. is sold or merged with another organization, your protected health information/medical record will become the property of the new owner.

 

This notice was published and becomes effective on April 14, 2003.