Drs. Kime, Kopan and Associates
Doctors of Optometry
4021 W. Sylvania Ave Toledo, Ohio 43623
419-475-6181ph 419-475-5750 fx
contact person: Linda Borrell
effective date of notice: April 14, 2003
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. PLEASE REVIEW CAREFULLY.
We respect our legal obligation to keep health information that identifies you private. We are obliged 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 healthcare operations. Examples of how we use of 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 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). “Health care operations” means 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 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 situation, 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 Federal Food and Drug Administration regarding drugs or medical devices
• Disclosure 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 of Medicare or Medicaid; or for investigation of possible violations of healthcare 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 suspected to be a victim of a crime, to provide information about a crime that happened somewhere else
• Disclosures 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 or tissue donations
• Uses of disclosures for health related research
• Uses or disclosures to prevent a serious threat to health or safety
• Uses or disclosures for specialized governmental functions, such as for the protection of the president of high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
• Disclosures of de-identified information
• Disclosures relating to worker’s compensation programs
• 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. 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, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not at 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 determines 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 its 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 form, we cannot make the use or disclosure. If you so 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 YOU HEALTH INFORMATION
The law gives you many rights regarding your health information.
• 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 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 email listed at the beginning of this document.
• Ask us to communicate with you in a confidential way, such as phoning you at work rather than at home, by mailing health information to a different address, or by using email to your personal email address. We will accommodate these requests if they are reasonable, and for an extra cost. To ask for confidential communication, send a written request to the office contact person at the address, fax, or email listed at the beginning of this document.
• Ask to see or 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 copies of your health information within 30 days of request (60 days if information is off-site). You may have to pay for copies 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 copies if we send you a written notice of the extension. If you want to review or get copies, send a written request to the office contact person at the address, fax, or email listed at the beginning of this document.
• Ask us to amend your health information if you think it is incorrect or incomplete. If we agree, we will amend the information within 60 days of request. We will send the corrected information to persons we know have the wrong information, and others that you specify. If we don not agree, you can write a statement of your positions and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position/rebuttal is included we will send it along when making permitted disclosure of your health information. By law, we may have a 30 day extension. If you want to amend your health information, send a written request to the office contact person at the address, fax, or email listed at the beginning of this document.
• Get a list of the disclosures that we have made of your health information within the past six years (or shorter). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization, incidental disclosures, those required by law and some other limited disclosers. You are entitled to one such list per year without charge; more frequent lists will need to be paid for in advance. We will usually respond to request of disclosures within 60 days, but are allowed a 30 day extension by law. If you want a list of disclosures, send a written request to the office contact person at the address, fax, or email listed at the beginning of this document.
• Get additional paper copies of this document upon request. It does not matter whether you receive 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 email listed at the beginning of this document.
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 notice n our office, have copies available in our office, and post it on our website (if applicable).
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the US Department of Health and Human Services, Office of 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 contact person at the address, fax, or email listed at the beginning of this document.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person or send a written request to the office contact person at the address, fax, or email listed at the beginning of this document.