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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. Dr. Donald A. Kammer is the Privacy
and Public Information Office of Vision Clinics, LLC, and is
considered the contact person for Middleburg Heights Vision Clinic and
West Park Vision Clinic locations.
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 usually will not ask you for special written
permission.
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;
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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