NOTICE OF PRIVACY PRACTICES—PACIFIC
EYECARE
This Notice of Privacy Practices is required by the Privacy Regulations
created as a result of the Health Insurance Portability and Accountability
Act (HIPAA) for 1996.
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.
Pacific EyeCare respects your privacy. We understand
that your Personal Health Information is very sensitive. We will
not disclose your information to others unless you tell us to do
so, or unless the law authorizes or requires us to do so.
The law protects the privacy of the health information we create
and obtain in providing our care and services to you. For example,
your protected health information includes your symptoms, test results,
diagnoses, treatment, health information from other providers, and
billing and payment information relating to these services. Federal
and state law allows us to use and disclose your protected health
information for purposes of treatment and health care operations.
State law requires us to get your authorization to disclose this
information for payment purposes.
Examples of Use and Disclosures of Protected Health Information
for Treatment, Payment, and Health Operations
For treatment:
- Information obtained by a nurse, physician, or other member
of our health care team will be recorded in your medical record
and used to help decide what care may be right for you.
- We may also provide information to others providing you
care. This will help them stay informed about your care.
For payment:
- We request payment from your health insurance plan. Health
plans need information from us about your medical care. Information
provided to health plans may include your diagnoses; procedures
performed, or recommended care.
- We may contact you by phone, leave messages on voice mail,
or send mail concerning payment collection issues.
For health care operations:
- We use your medical records to assess quality and improve
services.
- We may use and disclose medical records to review the
qualifications and performance of our health care providers and
to train our staff.
- We may contact you by phone or by mail to give you information
about treatment alternatives or other health-related benefits and
services.
- We may also contact you by phone, leave messages on voice
mail, or send postcards or letters by mail concerning appointments,
missed appointments or to reschedule appointments.
- We may use and disclose your information to conduct or
arrange for services, including:
- Medical quality review by your health plan;
- Accounting, legal, risk management, and insurance services;
- Audit functions, including fraud and abuse detection and
compliance programs.
Your Health Information Rights
The health and billing records we create and store are the property
of the practice/health care facility. The protected health information
in it, however, generally belongs to you. You have a right to:
- Receive, read, and ask questions about this Notice;
- Ask us to restrict certain uses and disclosures. You must
deliver this request in writing to us. We are not required to grant
the request. But we will comply with any request granted;
- Request and receive from us a paper copy of the most current
Notice of Privacy Practices for Protected Health Information (“Notice”);
- Request that you be allowed to see and get a copy of your
protected health information. You may make this request in writing.
We have a form available for this type of request.
- Have us review a denial of access to your health information—except
in certain circumstances;
- Ask us to change your health information. You may give
us this request in writing. You may write a statement of disagreement
if your request is denied. It will be stored in your medical record,
and included with any release of your records.
- When you request, we will give you a list of disclosures
of your health information. The list will not include disclosures
to third-party payors. You may receive this information without
charge once every 12 months. We will notify you of the cost involved
if you request this information more than once in 12 months.
- Ask that your health information be given to you by another
means or at another location. Please sign, date, and give us your
request in writing.
- Cancel prior authorizations to use or disclose health
information by giving us a written revocation. Your revocation does
not affect information that has already been released. It also does
not affect any action taken before we have it. Sometimes, you cannot
cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please
contact:
Office Manager, 360-779-2020, at our office here at 20669 Bond Rd., N.E.
Poulsbo, WA 98370. You may also contact your Physician
at the same address.
Our Responsibilities
We are required to:
- Keep your protected health information private;
- Give you this Notice;
- Follow the terms of this Notice.
We have the right to change our practices regarding the protected
health information we maintain. If we make changes, we will update
this Notice. You may receive the most recent copy of this Notice
by calling and asking for it or by visiting our office to pick one
up.
To Ask for Help or Complain
If you have questions, want more information, or want to report
a problem about the handling of your protected health information,
you may contact:
Office Manager, 20669 Bond Rd., N.E., Poulsbo, WA 98370,
360-779-2020. You may also contact your Physician at the same address.
If you believe your privacy rights have been violated, you may
discuss your concerns with any staff member. You may also deliver
a written complaint to the Office Manager as stated above. You may
also file a complaint with the U.S. Secretary of Health and Human
Services.
We respect your right to file a complaint with us or with the U.S.
Secretary of Health and Human Services. If you complain, we will
not retaliate against you.
Other Disclosures and Uses of Protected Health Information
Notification of Family and Others
· Unless you object, we may release health information about
you to a friend or family member who is involved in your medical
care. We may also give information to someone who helps pay for
your care. We may tell your family or friends your condition and
that you are in a hospital. In addition, we may disclose health
information about you to assist in disaster relief efforts.
You have the right to object to this use or disclosure of your
information. If you object, we will not use or disclose it.
We may use and disclose your protected health information without
your authorization as follows:
- With Medical Researchers—if the research has been
approved and has policies to protect the privacy of your health
information. We may also share information with medical researchers
preparing to conduct a research project.
- To Funeral Directors/Coroners consistent with applicable
law to allow them to carry out their duties.
- To Organ Procurement Organizations (tissue donation and
transplant) or persons who obtain, store, or transplant organs.
- To the Food and Drug Administration (FDA) relating to
problems with food, supplements, and products.
- To Comply With Workers’ Compensation Laws—if
you make a workers’ compensation claim.
- For Public Health and Safety Purposes as Allowed or Required
by Law:
- to prevent or reduce a serious, immediate threat to the
health or safety of a person
- or the public.
- to public health or legal authorities
- to protect public health and safety
- to prevent or control disease, injury, or disability
- to report vital statistics such as births or deaths.
- To Report Suspected Abuse or Neglect to public authorities.
- To Correctional Institutions if you are in jail or prison,
as necessary for your health and the health and safety of others.
- For Law Enforcement Purposes such as when we receive a
subpoena, court order, or other legal process, or you are the victim
of a crime.
- For Health and Safety Oversight Activities. For example,
we may share health information with the Department of Health.
- For Disaster Relief Purposes. For example, we may share
health information with disaster relief agencies to assist in notification
of your condition to family or others.
- For Work-Related Conditions That Could Affect Employee
Health. For example, an employer may ask us to assess health risks
on a job site.
- To the Military Authorities of U.S. and Foreign Military
Personnel. For example, the law may require us to provide information
necessary to a military mission.
- In the Course of Judicial/Administrative Proceedings at
your request, or as directed by a subpoena or court order.
- For Specialized Government Functions. For example, we
may share information for national security purposes.
Other Uses and Disclosures of Protected Health Information
- Uses and disclosures not in this Notice will be made only
as allowed or required by law or with your written authorization.
Web Site
- We have a Web site that provides information about us.
This address is: www.pacificeyecare.com. For your benefit, this
Notice is on the Web site.
Effective Date:
April 14, 2003
NOTICE OF PRIVACY PRACTICES—PACIFIC
EYECARE OF POULSBO
This notice of Privacy Practices is required by the Privacy Regulations
created as a result of the Health
Insurance Portability and Accountability Act (HIPPA) of 1996
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.
Pacific EyeCare of Poulsbo respects your privacy. We understand
that your
personal health information is very sensitive. We will not disclose
your information to others unless you tell us to do so, or unless
the law authorizes or requires us to do so.
The law protects the privacy of the health information we create
and obtain in providing our care and services to you. For example,
your protected health information includes your symptoms, test results,
diagnoses, treatment, health information from other providers, and
billing and payment information relating to these services. Federal
and state law allows us to use and disclose your protected health
information for purposes of treatment and health care operations.
State law requires us to get your authorization to disclose this
information for payment purposes.
Examples of Use and Disclosures of Protected Health Information
for Treatment, Payment, and Health Operations
For treatment:
- Information obtained by a nurse, physician, or other member
of our health care team will be recorded in your medical record
and used to help decide what care may be right for you.
- We may also provide information to others providing you
care. This will help them stay informed about your care.
For payment:
- We request payment from your health insurance plan. Health
plans need information from us about your medical care. Information
provided to health plans may include your diagnoses, procedures
performed, or recommended care.
- We may be contacting you by phone, leave messages on voice
mail or sending letters to you regarding payment collection.
For health care operations:
- We use your medical records to assess quality and improve
services.
- We may use and disclose medical records to review the
qualifications and performance of our health care providers and
to train our staff.
- We may contact you to remind you about appointments and
give you information about treatment alternatives or other health-related
benefits and services.
- We will be sending appointment recalls cards or letters
through the mail so you will know when to call and schedule your
appointment.
- We may be calling or sending a letter regarding any missed
appointments or if needing to reschedule your appointment.
- We may send you information on cosmetics and optical sales.
- We may use and disclose your information to conduct or
arrange for services, including:
- medical quality review by your health plan;
- accounting, legal, risk management, and insurance services;
- audit functions, including fraud and abuse detection and
compliance programs.
Your Health Information Rights
The health and billing records we create and store are the property
of the practice/health care facility. The protected health information
in it, however, generally belongs to you. You have a right to:
- Receive, read, and ask questions about this Notice;
- Ask us to restrict certain uses and disclosures. You must
deliver this request in writing to us. We are not required to grant
the request. But we will comply with any request granted;
- Request and receive from us a paper copy of the most current
Notice of Privacy Practices for Protected Health Information (“Notice”);
- Request that you be allowed to see and get a copy of your
protected health information. You may make this request in writing.
We have a form available for this type of request.
- Have us review a denial of access to your health information—except
in certain circumstances;
- Ask us to change your health information. You may give
us this request in writing. You may write a statement of disagreement
if your request is denied. It will be stored in your medical record,
and included with any release of your records.
- When you request, we will give you a list of disclosures
of your health information. The list will not include disclosures
to third-party payors. You may receive this information without
charge once every 12 months. We will notify you of the cost involved
if you request this information more than once in 12 months.
- Ask that your health information be given to you by another
means or at another location. Please sign, date, and give us your
request in writing.
- Cancel prior authorizations to use or disclose health
information by giving us a written revocation. Your revocation does
not affect information that has already been released. It also does
not affect any action taken before we have it. Sometimes, you cannot
cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please
contact:
Linda Welling, Office Manager
360-779-2020 ext 220 or 1-800-562-2020 ext 220
Our Responsibilities
We are required to:
- Keep your protected health information private;
- Give you this Notice;
- Follow the terms of this Notice.
We have the right to change our practices regarding the protected
health information we maintain. If we make changes, we will update
this Notice. You may receive the most recent copy of this Notice
by calling and asking for it or by visiting our office to pick one
up.
To Ask for Help or Complain
If you have questions, want more information, or want to report
a problem about the handling of your protected health information,
you may contact:
Linda Welling, Office Manager
1-360-779-2020 ext 220 or 1-800-562-2020 ext 220
If you believe your privacy rights have been violated, you may
discuss your concerns with any staff member. You may also deliver
a written complaint to the office manager at Pacific EyeCare of
Poulsbo. You may also file a complaint with the U.S. Secretary of
Health and Human Services.
We respect your right to file a complaint with us or with the U.S.
Secretary of Health and Human Services. If you complain, we will
not retaliate against you.
Other Disclosures and Uses of Protected Health Information
Notification of Family and Others
- Unless you object, we may release health information about
you to a friend or family member who is involved in your medical
care. We may also give information to someone who helps pay for
your care. We may tell your family or friends your condition and
that you are in a hospital. In addition, we may disclose health
information about you to assist in disaster relief efforts.
- You have the right to object to this use or disclosure of your
information. If you object, we will not use or disclose it.
- We may use and disclose your protected health information without
your authorization as follows:
- With Medical Researchers—if the research has been
approved and has policies to protect the privacy of your health
information. We may also share information with medical researchers
preparing to conduct a research project.
- To Funeral Directors/Coroners consistent with applicable
law to allow them to carry out their duties.
- To Organ Procurement Organizations (tissue donation and
transplant) or persons who obtain, store, or transplant organs.
- To the Food and Drug Administration (FDA) relating to
problems with food, supplements, and products.
- To Comply With Workers’ Compensation Laws—if
you make a workers’ compensation claim.
- For Public Health and Safety Purposes as Allowed or Required
by Law:
- to prevent or reduce a serious, immediate threat to the
health or safety of a person
- or the public.
- to public health or legal authorities
- to protect public health and safety
- to prevent or control disease, injury, or disability
- to report vital statistics such as births or deaths.
- To Report Suspected Abuse or Neglect to public authorities.
- To Correctional Institutions if you are in jail or prison,
as necessary for your health and the health and safety of others.
- For Law Enforcement Purposes such as when we receive a
subpoena, court order, or other legal process, or you are the victim
of a crime.
- For Health and Safety Oversight Activities. For example,
we may share health information with the Department of Health.
- For Disaster Relief Purposes. For example, we may share
health information with disaster relief agencies to assist in notification
of your condition to family or others.
- For Work-Related Conditions That Could Affect Employee
Health. For example, an employer may ask us to assess health risks
on a job site.
- To the Military Authorities of U.S. and Foreign Military
Personnel. For example, the law may require us to provide information
necessary to a military mission.
- In the Course of Judicial/Administrative Proceedings at
your request, or as directed by a subpoena or court order.
- For Specialized Government Functions. For example, we
may share information for national security purposes.
Other Uses and Disclosures of Protected Health Information
- Uses and disclosures not in this Notice will be made only
as allowed or required by law or with your written authorization.
Web Site
- We have a Web site that provides information about us.
For your benefit, this Notice is on the Web site at this address:
pacificeyecare.com.
Effective Date:
April 14, 2003