HIPAA Privacy Policy

My Family Vision Clinic
HIPAA Notice of Privacy Practices
212 West 9th Street
McCook, NE 69001
(308) 345-2954

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 calling the pharmacy to have them filled; showing you low vision aids; referring you to another doctor or clinic for eye care. 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; participation in managed care plans; and business planning. 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, unless it is required by law.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT SPECIAL 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/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 law enforcement purposes, such as to provide information about criminal activity.
• Disclosures 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
• 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 heath information
• 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 to remind you of scheduled appointments, or send you a letter 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 till us otherwise, we will mail you a reminder post card, and/or leave you a reminder message on your home answering machine or with someone who answers your hone if you are not home. The message and/or post card will state your appointment time or that your glasses and/or contact lenses have arrived for you to pick up.

OTHER USES AND DISCLOSURES

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this consent/authorization at anytime unless we have already acted in reliance upon it. Revocations must be in writing. Send the request to the office contact person named at the end 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 named at the end 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 named at the end of this Notice.

• Inspect, or get photocopies of your protected 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. If you want to review or get photocopies of your health information, send a written request to the office contact person named at the end of this Notice.

• Ask us to amend your health information if you think that it is incorrect or incomplete. If we deny your request, you have the right to file a statement of disagreement with us, and we will include it with your health information along with any rebuttal statement that we may write. 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 named at the end of the Notice.

• Get a list of the disclosures that we have made, if any, of your protect health information. If you want a list, send a written request o the office contact person named at the end of this Notice.

• Get additional paper copies of the Notice of Privacy Practices upon request.

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, and have copies available in our office.

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 named at the end of this Notice.

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.

Our contact person is our HIPAA Compliance officer: Natalie Marks

This Notice was published and becomes effective on April 14, 2003

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of this Notice of Privacy Practices. Date____________

Printed Patient Name: __________________________ Signature_____________________