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 Officer at the number listed at the end of this
Each time you visit a healthcare provider, a
record of your visit is made. Typically, this record contains your
symptoms, examination and test results, diagnoses, treatment, a plan for
future care or treatment, and billing-related information. This Notice
applies to all of the records of your care generated by your health care
Our office is required by law to maintain the privacy of your health
information and to provide you with a description of our legal duties and
privacy practices regarding your health information. The current Notice
will be posted in the waiting room and on our website at www.EyeLaserCenter.com.
The notice will include the effective date. In addition, we will make our
best effort to provide you with a copy of this notice that we request you
acknowledge with your signature.
We are required by law to abide by the terms of this Notice and notify you
if we make changes to this Notice, which may be at any time. Changes to
the Notice will apply to your medical information that we already maintain
as well as new information received after the change occurs. If we change
our Notice, it will be posted in the waiting room and on our website at www.EyeLaserCenter.com.
You may also request that a revised Notice be sent to you in the mail or
you may ask for one at your next appointment or appropriate visit. This
Notice will also serve to advise you as to your rights with regard to your
How We May Use and Disclose Medical
Information About You.
The following categories describe examples of the way we use and disclose
For Treatment: We may use medical information about you to
provide, coordinate and manage your treatment or services. We may disclose
medical information about you to other doctors, nurses, technicians,
medical students, or other personnel who are involved in your care. We may
also disclose medical information to clinical laboratories and imaging
facilities during the course of your care and treatment. For example, a
laboratory or medical specialist may need to know information about you to
run tests or to provide treatment.
- We may also provide a subsequent healthcare
provider with copies of various reports that should assist him or her
in treating you. For example, your medical information may be provided
to a physician to whom you have been referred so as to ensure that the
physician has appropriate information regarding your previous
treatment and diagnosis.
For Payment: We may use and disclose
medical information about your treatment and services to bill and collect
payment from you, your insurance company or a third party payer. For
example, we may need to give your insurance company information before it
approves or pays for the health care services we recommend for you. The
insurance company may use that information in connection with making a
determination of eligibility or coverage for insurance benefits, reviewing
services provided to you for medical necessity, and undertaking
utilization review activities. For example, obtaining approval for a
hospital stay may require that your relevant protected health information
be disclosed to the health plan to obtain approval for the hospital
For Health Care Operations:
We may use or disclose, as needed, your health information in order to
support our business activities. These activities may include, but are not
limited quality assessment activities, employee review activities,
training of medical students, fellows, licensing, marketing, legal advice,
accounting support, medical records storage and conducting or arranging
for other business activities. For example, we provide medical records to
a storage company for long-term safekeeping. In addition, we may also call
you by name in the waiting room when your physician is ready to see you.
We may use or disclose your protected health information, as necessary, to
contact you to remind you of your appointment by telephone.
Business Associates: There are some
services provided in our organization through contracts with business
associates. Examples include quality accounting, legal services, billing
services, transcription services, billing/collection agencies, and record
storage services. When these services are contracted, we may disclose your
health information to our business associate so that they can perform the
job that we have asked them to do and bill you or your third-party payer
for services rendered. To protect your health information, however, we
require the business associate to appropriately safeguard your information
through a written contract.
Other Permitted and Required Uses and
Disclosures That May Be Made With Your Consent, Authorization or
Opportunity to Object
We also may use and disclose your health
information as set forth below. You have the opportunity to agree or
object to the use or disclosure of all or part of your health information
in these instances. If you are not present or able to agree or object to
the use or disclosure of the health information (such as in an emergency
situation), then your clinician may, using professional judgment,
determine whether the disclosure is in your best interest. In this case,
only the information that is relevant to your health care will be
Individuals Involved in Your Care or Payment
for Your Care: Unless you object, we may release medical information
about you to a friend or family member who is involved in your medical
care or who helps to pay for your care. In addition, we may disclose
medical information about you to an entity assisting in a disaster relief
effort so that your family can be notified about your condition, status
Future Communications: We may communicate
to you via newsletters, mailings or other means regarding treatment
options; information on health-related benefits or services,
disease-management programs, wellness programs; to assess your
satisfaction with our services; to remind you that you have an appointment
for medical care; as part of fund raising efforts; for population based
activities relating to improving health or reducing health care costs; for
conducting training programs or reviewing competence of health care
professionals; or other community based initiatives or activities in which
our facility is participating. If you are not interested in receiving
these materials, please contact our Privacy Officer.
Other Permitted and Required Uses and
Disclosures That May Be Made Without Your Authorization or Opportunity to
We may use or disclose your health information in
the following situations without your authorization or without providing
you with an opportunity to object. These situations include:
As required by law. We may use and disclose health
information to the following types of entities, including but not limited
- Food and Drug Administration
- Public Health or Legal Authorities charged with
preventing or controlling disease, injury or disability
- Correctional Institutions
- Workers Compensation Agents
- Organ and Tissue Donation Organizations
- Military Command Authorities
- Health Oversight Agencies
- Funeral Directors, Coroners and Medical
- National Security and Intelligence Agencies
- Protective Services for the President and
- Authority that receives reports on abuse and
Law Enforcement/Legal Proceedings: We may disclose
health information for law enforcement purposes as required by law or in
response to a valid subpoena.
State-Specific Requirements: Many states have
requirements for reporting including population-based activities relating
to improving health or reducing health care costs.
Your Health Information Rights
Although your health record is the physical property of our office,
including Eye Laser Center, Robert M. Kershner, MD, PC or Chris M. Seniw,
MD that compiled it, you have the right to:
Inspect and Copy: You have the right
to inspect and copy medical information that may be used to make decisions
about your care. We ask that you submit these requests in writing.
Usually, this includes medical and billing records, but does not include
psychotherapy notes or information compiled in reasonable anticipation of,
or for use in, a civil, criminal, or administrative action or proceeding.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information, you may
request that the denial be reviewed. The person conducting the review will
not be the person who denied your request. We will comply with the outcome
of the review. Requests for access to and copies of your medical
information must be submitted to our office in writing. The cost for
copies is per Board Regulations.
Amend: If you feel that medical
information we have about you is incorrect or incomplete, you may ask us
to amend the information by submitting a request in writing. You have the
right to request an amendment for as long as we keep the information. We
may deny your request for an amendment and if this occurs, you will be
notified of the reason for the denial.
An Accounting of Disclosures: You
have the right to request an accounting of our disclosures of medical
information about you except for certain circumstances, including
disclosures for treatment, payment, health care operations or where you
specifically authorized a disclosure. Our office will provide the first
accounting to you in any 12-month period without charge. We will impose a
fee of $10.00 for each subsequent request for an accounting within the
12-month period. We ask that you submit these requests in writing.
Request Restrictions: You have the
right to request a restriction or limitation on the medical 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 medical
information we disclose about you to someone who is involved in your care
or the payment for your care, like a family member or friend. For example,
you could ask that we not use or disclose information about a procedure
that you had. We ask that you submit these requests in writing.
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 with emergency treatment.
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. We will agree to the
request to the extent that it is reasonable for us to do so. For example,
you can ask that we use an alternative address for billing purposes. We
ask that you submit these requests in writing.
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 this
notice electronically, you are still entitled to a paper copy of this
notice. To exercise any of your rights, please obtain the required forms
from the Privacy Officer and submit your request in writing.
If you believe your privacy rights have been violated,
you may file a complaint with us by calling and
asking for the Privacy Officer or by contacting
the Secretary of the Federal Department of Health
and Human Services. All complaints must also be
submitted in writing. You will not be penalized
for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information
not covered by this Notice or the laws that apply
to us will be made only with your written permission.
If you provide us permission to use or disclose
medical information about you, you may revoke that
permission, in writing, at any time. If you revoke
your permission, we will no longer use or disclose
medical information about you for the reasons covered
by your written authorization. However, we are unable
to take back any disclosures we have provided