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CENTRAL ARIZONA
EYE CLINIC,
PC DOING BUSINESS AS RUMMEL OPTICAL
Notice of Privacy Practices
for Protected Health Information
EffectiveDate: April 1,2003
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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
Central Arizona Eye Clinic, PC
is required to maintain the privacy of your health information
and to provide you with notice of its legal duties and privacy
practices.. This office will not use or disclose your health
information except as described in this Notice. This office
is permitted by federal privacy laws to make uses and disclosures
of your health information for purposes of treatment, payment,
and healthcare operations. Protected health information is
the information we create and obtain in providing our services
to yon. Such Information may include documenting you symptoms,
medical history, examination and test results, diagnosed,
treatment, and applying for future care or treatment. It also
includes billing documents for those services.
Examples of uses of your health information for treatment
purposes are:
A nurse or medical assistant obtains
treatment information about you and records it in a health
record.
During the course of your treatment, the physician determines
he/she will need to consult with another specialist in the
area. He/she will share the information with such specialist(s)
and obtain his/her input.
Examples of use of your health information for payment purposes:
We submit requests for payment to your health insurance company.
The health insurance company (or other business associate
helping us obtain payment) requests health information from
us regarding medical care given. We will provide information
to them about you and the care given, which may include copies
or excerpts of your medical record, which are necessary for
payment of your account. For example, a bill sent to your
health insurance company may include information that identifies
your diagnosis, and the procedures and supplies used.
Examples of use of your health information for healthcare
operations:
We obtain services from our insurers or other business associates
(an individual or entity under contract with us to perform
or assist us in a function or activity that necessitates the
use or disclosure of health information) such as quality assessment,
quality improvement, outcome evaluation, protocol and clinical
guidelines development, training programs, credentialing,
medical transcription, medical review, legal services, and
insurance. We will share health information about you with
our insurers or other business associates as necessary to
obtain these services. We require our insurers and other business
associates to protect the confidentiality of your health information.
YOUR HEALTH INFORMATION RIGHTS
The health and billing records
we maintain are the physical property of Central Arizona
Eye Clinic, PC The information in it, however, belongs to
you. You have a right to:
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o Request a restriction
on certain uses and disclosures of your health information
by delivering the request in writing to this office.
We are not required to grant the request,
but we will comply with any reasonable request submitted;
o Obtain a paper copy of the Notice of Privacy Practices
for Protected Health Information ("Notice")
by making a request to this office;
o Request that you be allowed to inspect and copy
your health record and billng record. You may exercise
this right by delivering the request in writing to
our office;
o Appeal a denial of access to your protected health
information except in certain circumstances;
o Request that your healthcare record be amended to
correct incomplete or incorrect information by delivering
a written request to our office. (The physician(s)
or other healthcare provider(s) is not required to
make such amendments.)
o File a statement of disagreement if your amendment
is denied, and require that the request for amendment
and any denial be attached in all future disclosures
of your protected health information;
o Obtain an accounting of disclosures of your health
information (as required to be maintained by law)
by delivering a written request to our office. An
accounting will not include internal uses of information
for treatment, payment, or operations; disclosures
made to you or made at your request; or disclosures
made to family members or friends in the course of
providing care;
o Request that communication of your health information
be made by alternative means or to an alternative
location by delivering the request in writing to our
office; and,
o Revoke authorizations that you made previously to
use or disclose information except to the extent information
or action has already been taken by delivering written
revocation to our office.
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If you want to exercise any of the above rights, please contact
the Human Resources Department,
Central Arizona Eye Clinic, P.C., 1022 Willow Creek Rd., Suite
200, Prescott, Arizona 86301 or telephone (928) 445-1341
in person or in writing, during normal working hours. You
will be provided with assistance on the steps to take to exercise
your rights.
You have the right to review this Notice before signing the
consent authorizing use and disclosure of your protected health
information for treatment, payment, and healthcare operations
purposes.
Our Responsibilities
Our office is required to:
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o Maintain the privacy of your health
information as required by law;
o Provide you with a notice as to our duties and privacy
as to the information we collect and maintain about
you;
o Abide by the terms of this Notice;
o Notify you if we cannot accommodate a requested restriction
or request; and
o Accommodate your reasonable requests regarding methods
to communicate health information to you. We reserve
the right to amend, change, or eliminate provisions
in our privacy practices and access practices and to
enact new provisions regarding the protected health
information we maintain. If our information practices
change, we will amend our Notice. You are entitled to
receive a revised copy of the Notice by calling and
requesting a copy of our "Notice" or by visiting
our office and picking up a copy. |
To Request Information or File a Complaint
If you have questions, would like additional information,
want to report a problem regarding the handling of your information,
or you believe your privacy rights have been violated, you
may deliver a written complaint to or contact by telephone
the Human Resources Department, Central Arizona Eye Clinic,
P.C., 1022 Willow Creek Rd., Prescott, AZ 86301, (928) 445-1341.
You may also file a complaint with the Secretary of Health
and Human Services, Washington, D.C..
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o We cannot, and will
not, require you to waive the right to file a complaint
with the Secretary of Health and Human Services (HHS)
or Office of Civil Rights (OCR) as a condition of receiving
treatment from the office,
o We cannot, and will not, retaliate against you for
filing a complaint with HHS or OCR. |
Other Disclosure and Uses
Notification of Family/Friends
Unless you object, we may use or disclose your health information
to notify or assist in notifying a family member, personal
representative, or other person responsible for your care,
about your location, and about your general condition, or
your death. Communication with
Family/Friends
Using our best judgment, we may disclose to family member,
other relative, close personal friend, or any other person
you identify, health information relevant to that person's
involvement in your care or in payment for such care if
you do not object or in an emergency.
Research
We may disclose your health information to researchers when
an institutional review board has approved the research
and has reviewed the research proposal and established protocols
to ensure the privacy of your health information.
Disaster Relief
We may use and disclose your health information to assist
in disaster relief efforts.
Deceased Persons
We may disclose your health information to funeral directors
or coroners consistent with applicable law to allow them
to carry out their duties.
Organ Procurement Organizations
Consistent with applicable law, we may disclose your health
information to organ procurement organizations or other
entities engaged in fee procurement, banking, or transplantation
of organs for the purpose of tissue donation and transplant.
Appointment Reminders and Treatment
Alternatives
We may contact you to provide you with appointment reminders,
with information about treatment alternatives, or with information
about other health-related benefits and services that may
be of interest to you.
Food and Drug Administration
(FDA)
We may disclose to the FDA your health information relating
to adverse events with respect to food, supplements, products
and product defects, or post-marketing surveillance information
to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation,
we may disclose your health information to the extent necessary
to comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your health information
to public health or legal authorities charged with preventing
or controlling disease, injury, or disability.
Abuse, Neglect, & Domestic
Violence
We may disclose your health information to public authorities
as allowed by law to report abuse, neglect, or domestic
violence. Inmates
If you are an inmate of a correctional institution or under
the custody of a law enforcement officer, we may disclose
to the institution or law enforcement official health information
necessary for your health and the health and safety of other
individuals. Law Enforcement
We may disclose your health information for law enforcement
purposes as required by law, such as when required by a
court order; for identification of a victim of a crime if
certain protective requirements are met; to report a crime
on our premises; to report crime in emergencies; and other
appropriate situations as permitted by law.
Health Oversight
We may disclose your health information to appropriate health
oversight agencies or for health oversight activities. Judicial/Administrative
Proceedings
We may disclose your health information in the course of
any judicial or administrative proceeding as allowed or
required by law or as directed by proper court order or
in response to a subpoena, discovery request, or other lawful
process if certain specific requirements are met. To avert
a serious threat to health or safety, we may disclose your
health information consistent with applicable-law to prevent
or lessen a serious, imminent threat to the health or safety
of a person or the public.
For Specialized Governmental
Functions
We may disclose your health information for specialized
government functions as authorized by law such as to Armed
Forces personnel, for national security purposes, or to
public assistance program personnel.
Other Uses
Uses and disclosures of your health information other than
those identified in this Notice will be made only as otherwise
authorized by law or with your written authorization and
you may revoke the authorization as previously provided.
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