Sumner Eye Care
NOTICE OF PRIVACY PRACTICES Effective Date of Notice: December 13, 2011
Thomas L. Graves, OD343 Hancock Street 305 South Broadway
Derek S. Peveler, ODGallatin, Tennessee 37066 Portland, Tennessee 37148
THIS NOTICE DESCRIBES HOW OPTOMETRIC & MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW CAREFULLY.
At Sumner Eye Care, we respect our legal obligation to keep health information that identifies you private. 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 this information.
TREATMENT, PAYMENT, & HEALTHCARE OPERATIONS:
The most common reasons we use or disclose your health information is for treatment, payment, or internal healthcare operations. By law, we are not required to receive your permission for these purposes. Examples of how we use/disclose information for treatment purposes are: setting up an appointment for you; testing and examining your eyes and vision; diagnosing the status of your vision and ocular health; prescribing medications or other treatment such as lasers, surgery, or rehabilitation; faxing information to fill prescriptions; showing you low-vision aids; referring you to another healthcare provider or clinic; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use/disclose your health information for payment purposes are: asking you about your health and vision insurance plans; asking about other sources of payment; verifying benefit enrollment and/or eligibility; preparing and sending bills or claims (either on paper or electronically); and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Healthcare operations” is defined as the administrative functions that we perform in order to run our offices. Examples of how we use/disclose your health information for healthcare operations are: financial or billing audits; internal quality assurance; participation in insurance and managed care plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our offices for these purposes without any specific permission – it is not required by law. If we need to disclose your health information outside our offices for these reasons, we usually will not ask for your specific permission. We will ask for specific written permission in the following situations: 1) marketing of products/services for which you are selected due to a condition you may have and for which we may receive payment, or when using that information your privacy may be compromised; 2) inclusion in medical studies or scientific research.
USES & DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION:
In some situations, the law requires us to use or disclose your information without your specific permission. Not all of these situations will apply to our offices or to you; some may never come up in our offices. Such uses or disclosures are:
- When State or Federal law mandates disclosures;
- For public health purposes to prevent the spread of contagious disease, serious threat to public health or safety, for public health research or healthcare operations, and notices to/from the Federal Food & Drug Administration regarding medications or medical devices;
- Disclosures regarding suspected victims of abuse, neglect, or domestic violence;
- Disclosures for regulatory oversight by licensing boards, Medicare/Medicaid audits, or for investigation of possible healthcare fraud;
- Disclosures for judicial and administrative proceedings (i.e. subpoenas or court orders);
- Disclosures for law enforcement purposes, to provide information about a crime, or to report a crime;
- Disclosure to a medical examiner, funeral director, or organizations that handle organ/tissue donation;
- Uses/disclosures for health-related research;
- Uses/disclosures relating to Worker’s Compensation programs;
- Incidental disclosures that are an unavoidable by-product of permitted use/disclosure;
- Disclosures to “business associates” who perform healthcare operations for us and who commit to respect the privacy of your healthcare information.
We may call/write/text/email to remind you of scheduled appointments, to notify you when you have missed an appointment, or that it is time to make an appointment for continuing care. If you refuse to allow us to contact you in such a manner, it may become necessary for us to recommend you seek care from another provider, especially if we feel your refusal jeopardizes your eye health and/or vision. While we respect your right to privacy, we insist that you become actively involved in your eye health care and cooperate with us in providing such care. We may also call/write/text/emailto notify you of new and/or different treatments or services available for your vision and eye health condition.
OTHER USES & DISCLOSURES:
We will not make any other uses or disclosures of your health information unless you sign a written Authorization Form. Federal law determines the content of an Authorization Form. We may, from time to time, initiate the “authorization process” if use or disclosure is our idea. Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. In this situation, you will give us written instructions and authorization, or you can use one of our standard forms.
If we initiate the process and ask you to complete an Authorization Form, you do not have to sign the authorization, and we cannot make the use or disclosure. If you do sign an Authorization Form, you may revoke it at any time (in writing), unless we have already acted in reliance upon the original authorization. Send revocations to the attentionof the individual named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
The law gives you many rights regarding your personally identifiable health information. You can:
- Ask us to restrict our use/disclosure for purposes of treatment (except emergencies), payment, or healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions you describe. To ask for restrictions, send a written request to the individual named on the front of this Notice.
- Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, or by mailing health information to a different address. We will make every attempt to accommodate these requests if they are reasonable and if you agree to pay us for any extra costs that may be involved. If you want to ask for confidential communications, send a written request to the individual named on the front of this Notice.
- 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/copy your health information within 30 days of written notice (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 impartial review of our decision, if legally available. By law, we may have one 30-day extension of time for us to give you access or photocopies if we send you written notice of the needed extension. If you want to review or get copies of your health information, send a written request to the individual named on the front of this Notice.
- Ask us to amend your health information if you think that it is incorrect or incomplete. We are not required to agree with your request. If we agree, we will amend the information within 60 days of the written request. We will send the corrected information to persons who we know have 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 feel necessary. We will not amend health information falsely. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your information, send a written request to the individual named on the front of this Notice.
- Get a list of the disclosures we have made of your health information that fall outside the parameters outlined in this Notice. You may request this information for any period up to and including six years from your last visit with us. By law, the list will not include: disclosures for purposes of treatment; payment or healthcare operations; disclosures with your authorization; incidental disclosures; and disclosures required by law (for a complete listing, see sections entitled Uses & Disclosures For Other Reasons Without Permission, Appointment Reminders, and Other Uses & Disclosures). You are entitled to one such list per year without charge. If you want more frequent lists, if applicable, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving your written notice. 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 the individual named on the front of this Notice.
- Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form previously. If you want additional copies, send a written request to the individual named on the front of this Notice.
OUR NOTICE OF PRIVACY PRACTICES:
We must abide by the terms of this Notice until we choose to make changes. We reserve the right to change this Notice at any time, as allowed by law. If we change the Notice, the new privacy policies will apply to your health information that we already have on file as well as to information we may create in the future. If we change our Notice of Privacy Practices, we will post the new Notice in our offices, have copies available in our offices, and post the Notice on our website. We, at Sumner Eye Care, are committed to the privacy of your health information and have established policies (in addition to those outlined in this Notice) that guide the training of our staff members in our Privacy Practices and agree (whenever possible or required by law) to abide by these practices.
If you think we may not have properly respected the privacy of your health information, you have the right to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We encourage you to notify us if you have a concern or complaint. We will make every attempt to investigate all legitimate reports. We will not retaliate against you if you make a complaint. If you want to register a concern or complaint, send a written statement or call the individual named on the front of this Notice.
FOR MORE INFORMATION:
If you would like more information about or Privacy Practices, please feel free to call or write the number or address listed on the front of this Notice.