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NOTICE OF PRIVACY PRACTICES AS REQUIRED BY THE PRIVACY
REGULATIONS CREATED AS A RESULT OF THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
Mitchell Refractive Surgery
and Eye Center
EFFECTIVE DATE OF THIS NOTICE: APRIL 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND
DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your
individually identifiable health information (PHI). In conducting
our business, we will create records regarding you and the
treatment and services we provide to you. We are required
by law to maintain the confidentiality of health information
that identifies you. We also are required by law to provide
you with this notice of our legal duties and the privacy practices
that we maintain in our practice concerning your PHI. By federal
and state law, we must follow the terms of the notice of privacy
practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide
you with the following important information:
" How we may use and disclose your PHI.
" Your privacy rights in your PHI.
" Our obligations concerning the use and disclosure
of your PHI.
The terms of this notice apply to
all records containing your PHI that are created or retained
by our practice. We reserve the right to revise or amend this
Notice of Privacy Practices. Any revision or amendment to
this notice will be effective for all of your records that
our practice has created or maintained in the past, and for
any of your records that we may create or maintain in the
future. Our practice will post a copy of our current Notice
in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Mitchell Eye Center Att: Privacy Officer at 22023 State
Rd 7 Suite 102 Boca Raton, FL, 33428 or call 561-451-0655.
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which
we may use and disclose your PHI.
1. Treatment. The information in your medical records
will be used to determine which treatment option best addresses
your health needs. The treatment selected will be documented
in your medial records so that other health care professional
can make informed decisions about your care. For example,
we may ask you to have laboratory tests, and we may use the
results to help us reach a diagnosis. Many of the people who
work for our practice - including, but not limited to, our
doctors and staff - may use or disclose your PHI in order
to treat you or to assist others in your treatment. Additionally,
we may disclose your PHI to others who may assist in your
care, such as your spouse, children or parents. Finally, we
may also disclose your PHI to other health care providers
for purposes related to your treatment.
2. Payment. Our practice may use and disclose your
PHI in order to bill and collect payment for the services
and items you may receive from us. For example, we may contact
your health insurer to certify that you are eligible for benefits
(and for what range of benefits), and we may provide your
insurer with details regarding your treatment to determine
if your insurer will cover, or pay for, your treatment. We
also may use and disclose your PHI to obtain payment from
third parties that may be responsible for such costs, such
as family members. Also, we may use your PHI to bill you directly
for services and items. We may disclose your PHI to other
health care providers and entities to assist in their billing
and collection efforts.
3. Health Care Operations. Our practice may use and
disclose your PHI to operate our business. As examples of
the ways in which we may use and disclose your information
for our operations, our practice may use your PHI to evaluate
the quality of care you received from us, or to conduct cost-management
and business planning activities for our practice. We may
disclose your PHI to other health care providers and entities
to assist in their health care operations.
4. Appointments and Reminders. Our practice may use
and disclose your PHI to contact you and remind you of an
appointment or as a follow up on treatment.
5. Non-Medical Communications. Our practice may use
your PHI to contact you for non-medical reasons. For example,
we may send you a birthday card or a holiday greeting via
mail.
6. Treatment Options. Our practice may use and disclose
your PHI to inform you of potential treatment options or alternatives.
We may treat you in an open treatment area and some incidental
PHI may be overheard by other patients being treated at the
same time.
7. Health-Related Benefits and Services. Our practice
may use and disclose your PHI to inform you of health-related
benefits or services that may be of interest to you. For example,
we may send you newsletters that may include information about
our practice, health related issues and products and services.
8. Release of Information to Family/Friends. Our practice
may release your PHI to a friend or family member that is
involved in your care, or who assists in taking care of you.
For example, a parent or guardian may ask that a babysitter
take their child to the pediatrician's office for treatment
of a cold. In this example, the babysitter may have access
to this child's medical information.
9. Disclosures Required By Law. Our practice will
use and disclose your PHI when we are required to do so by
federal, state or local law.
D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which
we may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may disclose
your PHI to public health authorities that are authorized
by law to collect information for the purpose of:
A. maintaining vital records, such as births and deaths;
B. reporting child abuse or neglect;
C. preventing or controlling disease, injury or disability;
D. notifying a person regarding potential exposure to a
communicable disease;
E. notifying a person regarding a potential risk for spreading
or contracting a disease or condition;
F. reporting reactions to drugs or problems with products
or devices;
G. notifying individuals if a product or device they may
be using has been recalled;
H. notifying appropriate government agency (ies) and authority
(ies) regarding the potential abuse or neglect of an adult
patient (including domestic violence); however, we will
only disclose this information if the patient agrees or
we are required or authorized by law to disclose this information;
and
I. notifying your employer under limited circumstances
related primarily to workplace injury or illness or medical
surveillance.
2. Health Oversight Activities. Our practice may
disclose your PHI to a health oversight agency for activities
authorized by law. Oversight activities can include, for example,
investigations, inspections, audits, surveys, licensure and
disciplinary actions; civil, administrative, and criminal
procedures or actions; or other activities necessary for the
government to monitor government programs, compliance with
civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice
may use and disclose your PHI in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding.
We also may disclose your PHI in response to a discovery request,
subpoena, or other lawful process by another party involved
in the dispute, but only if we have made an effort to inform
you of the request or to obtain an order protecting the information
the party has requested.
4. Law Enforcement. We may release PHI if asked to
do so by a law enforcement official:
A. Regarding a crime victim in certain situations, if we
are unable to obtain the person's agreement;
B. Concerning a death we believe has resulted from criminal
conduct;
C. Regarding criminal conduct at our offices;
D. In response to a warrant, summons, court order, subpoena
or similar legal process;
E. To identify/locate a suspect, material witness, fugitive
or missing person; and
F. In an emergency, to report a crime (including the location
or victim(s) of the crime, or the description, identity
or location of the perpetrator).
5. Deceased Patients. Our practice may release PHI
to a medical examiner or coroner to identify a deceased individual
or to identify the cause of death. If necessary, we also may
release information in order for funeral directors to perform
their jobs.
6. Organ and Tissue Donation. Our practice may release
your PHI to organizations that handle organ, eye or tissue
procurement or transplantation, including organ donation banks,
as necessary to facilitate organ or tissue donation and transplantation
if you are an organ donor.
7. Research. Our practice may use and disclose your
PHI for research purposes in certain limited circumstances.
We will obtain your written authorization to use your PHI
for research purposes except when an Internal Review
Board or Privacy Board has determined that the waiver of your
authorization satisfies the following: (i) the use or disclosure
involves no more than a minimal risk to your privacy based
on the following: (A) an adequate plan to protect the identifiers
from improper use and disclosure; (B) an adequate plan to
destroy the identifiers at the earliest opportunity consistent
with the research (unless there is a health or research justification
for retaining the identifiers or such retention is otherwise
required by law); and (C) adequate written assurances that
the PHI will not be re-used or disclosed to any other person
or entity (except as required by law) for authorized oversight
of the research study, or for other research for which the
use or disclosure would otherwise be permitted; (ii) the research
could not practicably be conducted without the waiver; and
(iii) the research could not practicably be conducted without
access to and use of the PHI.
8. Serious Threats to Health or Safety. Our practice
may use and disclose your PHI when necessary to reduce or
prevent a serious threat to your health and safety or the
health and safety of another individual or the public. Under
these circumstances, we will only make disclosures to a person
or organization able to help prevent the threat.
9. Military. Our practice may disclose your PHI if
you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your
PHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your PHI
to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your PHI to
correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement
official. Disclosure for these purposes would be necessary:
(a) for the institution to provide health care services to
you, (b) for the safety and security of the institution, and/or
(c) to protect your health and safety or the health and safety
of other individuals.
12. Workers' Compensation. Our practice may release
your PHI for workers' compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain
about you:
1. Confidential Communications. You have the right
to request that our practice communicate with you about your
health and related issues in a particular manner or at a certain
location. For instance, you may ask that we contact you at
home, rather than work. In order to request a type of confidential
communication, you must make a written request to Mitchell
Eye Center Att: Privacy Officer 22023 State Rd 7 Suite 102
Boca Raton, FL 33428 specifying the requested method of
contact, or the location where you wish to be contacted. Our
practice will accommodate reasonable requests. You
do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to
request a restriction in our use or disclosure of your PHI
for treatment, payment or health care operations. Additionally,
you have the right to request that we restrict our disclosure
of your PHI to only certain individuals involved in your care
or the payment for your care, such as family members and friends.
We are not required to agree to your request; however,
if we do agree, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information
is necessary to treat you. In order to request a restriction
in our use or disclosure of your PHI, you must make your request
in writing to Mitchell Eye Center Att: Privacy Officer
22023 State Rd 7 Suite 102 Boca Raton FL, 33428. Your
request must describe in a clear and concise fashion:
A. the information you wish restricted;
B. whether you are requesting to limit our practice's use,
disclosure or both; and
C. to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect
and obtain a copy of the PHI that may be used to make decisions
about you, including patient medical records and billing records,
but not including psychotherapy notes. You must submit your
request in writing to Mitchell Eye Center Att: Privacy Officer
22023 State Rd 7 Suite 102 Boca Raton FL, 33428 in order to
inspect and/or obtain a copy of your PHI. Our practice may
charge a fee for the costs of copying, mailing, labor and
supplies associated with your request. Our practice may deny
your request to inspect and/or copy in certain limited circumstances;
however, you may request a review of our denial. Another licensed
health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health
information if you believe it is incorrect or incomplete,
and you may request an amendment for as long as the information
is kept by or for our practice. To request an amendment, your
request must be made in writing and submitted to Mitchell
Eye Center Att: Privacy Officer 22023 State Rd 7 Suite 102
Boca Raton FL, 33428. You must provide us with a reason
that supports your request for amendment. Our practice will
deny your request if you fail to submit your request (and
the reason supporting your request) in writing. Also, we may
deny your request if you ask us to amend information that
is in our opinion: (a) accurate and complete; (b) not part
of the PHI kept by or for the practice; (c) not part of the
PHI which you would be permitted to inspect and copy; or (d)
not created by our practice, unless the individual or entity
that created the information is not available to amend the
information.
5. Accounting of Disclosures. All of our patients
have the right to request an "accounting of disclosures."
An "accounting of disclosures" is a list of certain
non-routine disclosures our practice has made of your PHI
for non-treatment, non-payment or non-operations purposes.
Use of your PHI as part of the routine patient care in our
practice is not required to be documented. For example, the
doctor sharing information with the nurse; or the billing
department using your information to file your insurance claim.
In order to obtain an accounting of disclosures, you must
submit your request in writing to Mitchell Eye Center Att:
Privacy Officer 22023 State Rd 7 Suite 102 Boca Raton FL,
33428.
All requests for an "accounting of disclosures"
must state a time period, which may not be longer than six
(6) years from the date of disclosure and may not include
dates before April 14, 2003. The first list you request within
a 12-month period is free of charge, but our practice may
charge you for additional lists within the same 12-month period.
Our practice will notify you of the costs involved with additional
requests, and you may withdraw your request before you incur
any costs.
6. Right to a Paper Copy of This Notice. You are entitled
to receive a paper copy of our notice of privacy practices.
You may ask us to give you a copy of this notice at any time.
To obtain a paper copy of this notice, contact Mitchell
Eye Center Att: Privacy Officer 22023 State Rd 7 Suite 102
Boca Raton FL, 33428.
7. Right to File a Complaint. If you believe your
privacy rights have been violated, you may file a complaint
with our practice or with the Secretary of the Department
of Health and Human Services. To file a complaint with our
practice, contact Mitchell Eye Center Att: Privacy Officer
22023 State Rd 7 Suite 102 Boca Raton FL, 33428. All complaints
must be submitted in writing. You will not be penalized
for filing a complaint.
8. Right to Provide an Authorization for Other Uses and
Disclosures. Our practice will obtain your written authorization
for uses and disclosures that are not identified by this notice
or permitted by applicable law. Any authorization you provide
to us regarding the use and disclosure of your PHI may be
revoked at any time in writing. After you revoke your
authorization, we will no longer use or disclose your PHI
for the reasons described in the authorization. Please note,
we are required to retain records of your care.
Again, if you have any questions regarding this notice or
our health information privacy policies, please contact Mitchell
Eye Center Att: Privacy Officer 22023 State Rd 7 Suite 102
Boca Raton FL, 33428.
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