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NOTICE
OF PRIVACY PRACTICES
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 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, uses or disclosures for 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 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 in our office; or to report a crime that
happened somewhere else, 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 or 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 to tell you
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 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” with content mandated
by federal law. We may initiate the authorization process if the use or
disclosure is our idea or you may initiate the process 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 to the Compliance Officer at our office.
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 Compliance
Officer at our office.
• Ask us to communicate with you in a confidential way, such as by phoning
you at work rather than at home. We will accommodate these requests if they are
reasonable, and if you pay us for any extra cost involved. If you want to ask
for confidential communications, send a written request to the Compliance
Officer at our office.
• Ask to see or get photocopies of your health information. By law, there
are a few limited situations in which we can refuse to permit access or
copying. However, for the most part, you will be able to review or have a copy
of your health information within 15 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 Compliance Officer at our office.
• 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 Compliance Officer at our office.
• Obtain 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 or additional paper copies of this Notice of Privacy Practices,
send a written request to our Compliance Officer.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practice (NPP)
until we revise it. We reserve the right to change this notice at any time as
allowed by law. If we change the NPP, 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 NPP, we will post the new
notice in our office, make copies available and post it on our Website.
FOR MORE INFORMATION
If you think that we have not properly respected the privacy of your health
information, you are free to complain to our office or to 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 prefer to complain directly to us
or want more information regarding our privacy practices, please contact the
Compliance Officer, Safeiah Alwarith, by writing: My Eye Dr., 1950 Old
Gallows Road, Suite 100, Vienna, VA 22182; or by calling: 703-847-8899
x231; or emailing: salwarith@myeyedr.com
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