Effective Date of Notice: January 31, 2017 NOTICE OF PRIVACY PRACTICES Isthmus Eye Care S.C. www.isthmuseye.com 7601 University Ave. Ste. 102 Middleton, WI 53562 608­831­3366 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. We respect our legal obligation to keep health information that identifies you private. We a re obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information a nd what rights you have regarding it. TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS The most c ommon reason why we use or disclose your health information is for treatment, payment or health care operations. ● Examples of how we use or disclose information for treatment purposes a re: setting up a n a ppointment for you; testing or e xamining your e yes; prescribing glasses, c ontact lenses or e ye medications a nd faxing them to be filled; showing you low vision a ids; referring you to a nother doctor or c linic for e ye care or low vision a ids or services; or getting c opies of your health information from a nother professional that you may have seen before us. ● Examples of how we use or disclose your health information for payment purposes a re: a sking a bout your health or vision c are plans, or other sources of payment; preparing a nd sending bills or c laims; a nd collecting unpaid a mounts (either ourselves or through a c ollection a gency or a ttorney). ● Examples of how we use or disclose your health information for health c are operations a re: financial or billing a udits; internal quality a ssurance; personnel decisions; participation in managed c are plans; defense of legal matters; business planning; a nd outside storage of our records.“Health c are operations” mean those a dministrative a nd managerial functions that we have to do in order to run our office. We routinely use your health information inside our office for these purposes without a ny special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not a sk you for special written permission. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law a llows or requires us to use or disclose your health information without your permission. Not a ll of these situations will a pply to us; some may never c ome up a t our office a t a ll. Such uses or disclosures a re: ● When a state or federal law mandates that c ertain health information be reported for a specific purpose; ● For public health purposes, such a s c ontagious disease reporting, investigation or surveillance; a nd notices to a nd from the federal Food a nd Drug Administration regarding drugs or medical devices; ● To governmental a uthorities a bout victims of suspected a buse, neglect or domestic violence; ● Health oversight a ctivities, such a s for the licensing of doctors; for a udits by Medicare a nd Medicaid; or for investigation of possible violations of health c are laws; ● For judicial a nd a dministrative proceedings, such a s in response to subpoenas or orders of c ourts or administrative a gencies; ● For law e nforcement purposes, such a s to provide information a bout someone who is or is suspected to be a victim of a c rime; to provide information a bout a c rime a t our office; or to report a c rime that happened somewhere e lse; ● To a medical e xaminer to identify a dead person or to determine the c ause of death; or to funeral directors to a id in burial; or to organizations that handle organ or tissue donations; ● For health related research; ● To prevent a serious threat to health or safety; ● For specialized government functions, such a s for the protection of the president or high ranking government officials; for lawful national intelligence a ctivities; for military purposes; or for the evaluation a nd health of members of the foreign service; ● De­identified information; ● Relating to worker’s c ompensation programs; ● A “ limited data set” for research, public health, or health c are operations; ● Incidental disclosures that a re a n unavoidable by­product of permitted uses or disclosures; ● To “ business a ssociates” who perform health c are operations for us a nd who c ommit to respect the privacy of your health information; APPOINTMENT REMINDERS We may c all, e mail, text or mail you to remind you of scheduled a ppointments, or that it is time to make a routine appointment. We may a lso notify you of other treatments or services a vailable a t our office that might help you. Unless you tell us otherwise, we may leave you a reminder message on your home a nswering machine or with someone who a nswers your phone if you a re not home. OTHER USES AND DISCLOSURES We will not make a ny other uses or disclosures of your health information unless you sign a written “authorization form”. The c ontent of a n “ authorization form” is determined by federal law. Sometimes, we may initiate the a uthorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone e lse. Typically, in this situation you will give us a properly c ompleted a uthorization form, or you c an use one of ours. If we initiate the process a nd a sk you to sign a n a uthorization form, you do not have to sign it. If you do not sign the a uthorization, we c annot make the use or disclosure. If you do sign one, you may revoke it a t a ny time unless we have a lready a cted in reliance upon it. Revocations must be in writing. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You c an a sk us: ● To restrict our uses a nd disclosures for purposes of treatment (except e mergency treatment), payment or health c are operations. ○ We do not have to a gree to do this, but if we a gree, we must honor the restrictions that you want. To a sk for a restriction, send a written request to the office. ● To c ommunicate with you in a c onfidential way, such a s by phoning you a t work rather than a t home, by mailing health information to a different a ddress, or by using e mail to your personal e mail a ddress. ○ We will a ccommodate these requests if they a re reasonable, a nd if you pay us for a ny e xtra c ost. If you want to a sk for c onfidential c ommunications, send a written request to the office. ● To see or to get photocopies of health information. ○ By law, there a re a few limited situations in which we c an refuse to permit a ccess or c opying. For the most part, however, you will be a ble to review or have a c opy of your health information within 30 days of a sking us (or sixty days if the information is stored off–site). You may have to pay for photocopies in a dvance. If we deny your request, we will send you a written e xplanation and instructions a bout how to get a n impartial review of our denial if one is legally a vailable. By law, we c an have one 30 day e xtension of time to give you a ccess or photocopies if we send you a written notice of the e xtension. If you want to review or get photocopies of your health information, send a written request to the office. ● To a mend your health information if you think that it is incorrect or incomplete. ○ If we a gree, we will a mend the information within 60 days from when you a sk us. We will send ○
the c orrected information to the person who we know got the wrong information, a nd a ny others that you specify. If we do not a gree, you c an write a statement of your position, a nd we will include it with your health information a long with a ny rebuttal statement that we may write. Once your statement of position a nd/or our rebuttal is included in your health information, we will send it a long whenever we make a permitted disclosure of your health information. By law, we c an have one 30 day e xtension of time to c onsider a request for a mendment if we notify you in writing of the extension. If you want to a sk us to a mend your health information, send a written request, including your reasons for the a mendment, to the office. ●
To 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). ○ By law, the list will not include: disclosures for purpose of treatment, payment or health c are operations; disclosures with your a uthorization; incidental disclosures; disclosures required by law; a nd some other limited disclosures. ○ You a re e ntitled to one such list per year without c harge. If you want more frequent lists, you will have to pay for them in a dvance. We will usually respond to your request within 60 days of receiving it, but by law we c an have one 30 day e xtension of time if we notify you of the extension in writing. If you want a list, send a written request to the office. OUR NOTICE OF PRIVACY PRACTICES By law, we must a bide by the terms of this Notice of Privacy Practices until we c hoose to c hange it. We reserve the right to c hange this notice a t a ny time a s a llowed by law. If we c hange this Notice, the new privacy practices will a pply to your health information that we a lready have a s well a s to such information that we may generate in the future. If we c hange our Notice of Privacy Practices, we will post the new notices in our office, have c opies a vailable in our office, a nd post it on our website. COMPLAINTS ●
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You c an c omplain if you feel we have violated your rights by c ontacting us using the information on the top of page 1. You c an file a c omplaint with the U.S. Department of Health a nd Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W. Washington, D.C., 20201, c alling 1­877­696­6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/ . We will not retaliate a gainst you for filing a c omplaint. FOR MORE INFORMATION If you want more information a bout our privacy practices, c all the office.