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Effective date of notice: April 14, 2003.
NOTICE OF PRIVACY PRACTICES
Robert W. Aube Jr., O.D. Catherine M. Ferentini, O.D. and Alison Baikal, O.D.
Visual Perceptions, L.L.C.
2139 Silas Deane Highway
Rocky Hill, CT 06067
(860) 529-9740
Fax (860) 563-8483
Email: robertwaubejr@visualperceptions.com
Contact Person: Anne Cartelli
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 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 it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common 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 are: setting up an appointment
for you; testing or examining your eyes; prescribing glasses, contact
lenses, or eye medications and faxing them to be filled; showing you low
vision aids; referring you to another doctor or clinic for eye care or low
vision aids or services; or getting copies of your health information from
another professional that you may have seen before us. Examples of how we
use or disclose your health information for payment purposes are: asking you
about your health or vision care plans, or other sources of payment;
preparing and sending bills or claims; and collecting unpaid amounts (either
ourselves or through a collection agency or attorney). “Health care
operations” mean those administrative and managerial functions that we have
to do in order to run our office. Examples of how we use or disclose your
health information for health care operations are: financial or billing
audits; internal quality assurance; personnel decisions; participation in
managed care plans; defense of legal matters; business planning; and outside
storage of our records.
We routinely use your health information inside our office for these
purposes without any special permission. If we need to disclose your health
information outside of our office for these reasons, We may ask you for
special written permission.
[We will ask for special written permission in the following situations:
outside of normal business operations.]
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
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 federal 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 of de-identified information;
- disclosures relating to worker’s compensation programs;
- disclosures of a “limited data set” for research, public health, or
health care operations;
- incidental disclosures that are an unavoidable by-product of permitted
uses or disclosures;
- disclosures to “business associates” who perform health care
operations for us and who commit to respect the privacy of your health
information;
- [specify other uses and disclosures affected by state law].
Unless you object, we will also share relevant information about your
care with your family or friends who are helping you with your eye care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it
is time to make a routine appointment. We may also call or write to notify
you of other treatments or services available at our office that might help
you. Unless you tell us otherwise, we will mail you an appointment reminder
on a post card, and/or leave you a reminder message on your home answering
machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information
unless you sign a written “authorization form.” The content of an
“authorization form” is determined by federal law. Sometimes, we may
initiate the authorization 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 else. Typically, in this situation you will give
us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you
do not have to sign it. If you do not sign the authorization, we cannot make
the use or disclosure. If you do sign one, you may revoke it at any time
unless we have already acted in reliance upon it. Revocations must be in
writing. Send them to the office contact person named at the beginning of
this Notice.
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 the
office contact person at the address, fax or E Mail shown at the beginning
of this Notice.
- 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 the office contact person at the address, fax or
E mail shown at the beginning of this Notice.
- 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 (or sixty
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 how to get an impartial review
of our denial if one is legally available. 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 the
office contact person at the address, fax or E mail shown at the beginning
of this Notice.
- 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 you 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 the office contact
person at the address, fax or E mail shown at the beginning of this
Notice.
- 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 purposes of treatment,
payment or health care operations; disclosures with your authorization;
incidental disclosures; disclosures required by law; 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 the office contact person at the address, fax or E mail shown
at the beginning 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 already. If you want additional paper copies, send a written request
to the office contact person at the address, fax or E mail shown at the
beginning of this Notice.
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 as allowed by law. 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, have
copies available in our office, and post it on our Web site.
COMPLAINTS
If you think that we have not properly respected the privacy of your
health information, you are free to complain to us or 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 the office contact person at the address, fax or E mail
shown at the beginning of this Notice. If you prefer, you can discuss your
complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit
the office contact person at the address or phone number shown at the
beginning of this Notice.
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