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PRIVACY NOTICE

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 THIS INFORMATION CAREFULLY.

WHO WILL FOLLOW THIS NOTICE This notice describes the privacy practices of Optometric Associates of Warren County P.C. All of our physicians and staff may have access to information in your chart for treatment, payment and health care operations, which are described below, and may use and disclose information as described in this Notice. This Notice also applies to any volunteer or trainee we allow to help you while seeking services from us.

OUR PLEDGE REGARDING THE PRIVACY OF YOUR MEDICAL INFORMATION Your medical information includes information about your physical and mental health. We understand that information about your physical and mental health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to any and all of the records of your care generated by us.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. This notice covers treatment, payment, and what are called health care operations, as discussed below. It also covers other uses and disclosures for which a consent or authorization are not necessary. Where Iowa law is more protective of your medical information, we will follow state law, as explained below.

We use information for treatment purposes, when, for example, we set up an appointment for you, when our technician or doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when the doctor prescribes medication, when our staff helps you select and order glasses or contact lenses. We may disclose your health information outside of our office for treatment purposes if, for example, we refer you to another doctor or clinic for eye care or low vision aids or services, if we send a prescription for glasses or contacts to another to be filled, when we provide a prescription for medication to a pharmacist, or when we phone to let you know that your glasses or contact lenses are ready to be picked up. Sometimes we may ask for copies of your health information from another professional that you may have seen before us.

We use your health information for payment purposes when, for example, our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services, when we prepare bills to send to you or your health or vision care plan, when we process payment by credit card, and when we try to collect unpaid amounts due. We may disclose your health information outside of our office for payment purposes when, for example, bills or claims for payment are mailed, faxed, or sent by computer to your or your health or vision plan, or when we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.

We use and disclose your health information for health care operations in a number of ways. Health care operations means those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.

We may release medical information (including mental health information), about you to a family member who is involved in your medical care without consent or authorization. We may also give medical information, including prescription information or information concerning your appointments to friends who are involved in your care. We may also give such information to someone who helps pay for your care.

USES AND DISCLOSURES WITHOUT CONSENT OR AUTHORIZATION 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 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 for 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 or 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 for the evaluation and health of members of the foreign service

• disclosures relating to worker?s compensation programs

• disclosures to business associates who perform health care operations for us and who agree to keep your health information private

 

APPOINTMENT REMINDERS We may call to remind you of scheduled appointments. We may also call to notify you of other treatments or services available at our office that might help you.

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 as set out in an authorization signed by you. 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. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

 

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 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

• 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

• 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. 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 required. 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

• 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 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

• 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), except disclosures for purposes of treatment, payment or health care operations 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

• get additional paper copies of this Notice of Privacy Practices upon request, no matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written notice to Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125.

COMPLAINTS 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 Optometric Associates of Warren County P.C. at 225 W. Ashland Indianola, IA 50125. If you prefer, you can discuss your complaint in person or by phone.

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 in compliance with and as allowed by law without additional notice to you. 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 in our office, and have copies available in our office.





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