Effective Date: October 1, 2016
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.
If you have any questions about this notice, please contact our privacy official at 503-954-2817 or at email@example.com.
Who Will Follow This Notice?
This notice describes the information privacy practices followed by our employees, staff and other personnel.
Your Health Information
This notice applies to the information and records we have about you, your health, health status, and the health care and services you receive from Revant Optics. Your health information may include information created and received by Revant Optics, may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information.
We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
How We May Use and Disclose Health Information About You
We may use and disclose health information for the following purposes:
We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, staff or other personnel who are involved in taking care of you and your health.
Different personnel in our organization may share information about you and disclose information to people who do not work for Revant Optics in order to coordinate your care, such as sending prescriptions to Revant Optics’ lab. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have. We will request your permission before sharing health information with your family or friends unless you are unable to give permission to such disclosures due to your health condition.
We may use and disclose health information about you so that the treatment and services you receive at Revant Optics may be billed to and payment may be collected from you, an insurance company or a third party.
For example, we may need to give your vision plan information about the filling of a lens prescription so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a prescription you have submitted to us to obtain prior approval or to determine whether your plan will pay for the treatment.
For Health Care Operations
We may use and disclose health information about you in order to run Revant Optics and make sure that you and our other patients receive quality care.
For example, we may use your health information to evaluate the performance of our staff in providing assistance to you in obtaining the glasses or contacts you would like to order. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law
We will disclose health information about you when required to do so by federal, state or local law.
Military, Veterans, National Security and Intelligence
If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Public Health Risks
We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities
We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Information Not Personally Identifiable
We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends
We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse if your spouse is also on the phone with you when discussing your prescription with our staff.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions.
Other Uses and Disclosures of Health Information
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. Examples of disclosures requiring your authorization include disclosures to your partner, your spouse, your children and your legal counsel.
We also will not use or disclose your health information for the following purposes without your specific, written Authorization:
For our marketing purposes
This does not including face-to-face communication about products or services that may be of benefit to you and about prescriptions you have already been prescribed.
For the purpose of selling your health information.
We may receive payment for sharing your information for, as an example, public health purposes, research, and releases to you or others you authorize a release to as long as payment is reasonable and related to the cost of providing your health information.
If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
Uses and Disclosures that Require Us to Give You an Opportunity to Object
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy
You have the right to inspect and copy your health information, such as medical and billing records, that we keep and use to make decisions about your care. You have the right to request an electronic copy of your record in the format of your choosing if we store your medical information electronically. If we are unable to provide you an electronic copy of your record in the format requested, we will provide a copy in .pdf form. You must submit a written request to our privacy official in order to inspect and/or copy records of your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. A modified request may include requesting a summary of your medical record.
If you request to view a copy of your health information, we will not charge you for inspecting your health information. If you wish to inspect your health information, please submit your request in writing to our privacy official. You have the right to request a copy of your health information in electronic form if we store your health information electronically.
We may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to, health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend
If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by Revant Optics.
To request an amendment, complete and submit a medical record amendment/correction form to our privacy official.
We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny or partially deny your request if you ask us to amend information that:
- – We did not create, unless the person or entity that created the information is no longer available to make the amendment
- – Is not part of the health information that we keep
- – You would not be permitted to inspect and copy
- – Is accurate and complete
If we deny or partially deny your request for amendment, you have the right to submit a rebuttal and request the rebuttal be made a part of your medical record. Your rebuttal needs to be two pages in length or less and we have the right to file a rebuttal responding to yours in your medical record. You also have the right to request that all documents associated with the amendment request (including rebuttal) be transmitted to any other party any time that portion of the medical record is disclosed.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, when specifically authorized by you and a limited number of special circumstances involving national security, correctional institutions and law enforcement.
To obtain this list, you must submit your request in writing to our privacy official. It must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information.
We are required to agree to your request if you pay for treatment, services, supplies and prescriptions “out of pocket” at the time of service and you request the information not be communicated to your health plan for payment or health care operations purposes. There may be instances where we are required to release this information if required by law.
To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information to our privacy official.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you may complete and submit the Request for Restriction On Use/Disclosure of Medical Information and/or Confidential Communication to our privacy official. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. You may also find a copy of this Notice on our web site.
To obtain such a copy, contact our privacy official.
Changes to This Notice
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. You are entitled to a copy of the notice currently in effect.
We will inform you of any significant changes to this Notice. This may be through our newsletter, a sign prominently posted at our location(s), a notice posted on our web site or other means of communication.
Breach of Health Information
We will inform you if there is a breach of your unsecured health information.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services at:
Office for Civil Rights Region [Region Covered Entity is located in]
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
To file a complaint with Revant Optics, contact Revant Optics Privacy Official at 503-954-2817 or at firstname.lastname@example.org
You will not be penalized for filing a complaint.