Effective Date: April 9, 2019
Wilkinson Eye Center
Notice of Privacy Practices for Protected Health Information
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 THE HIPAA PRIVACY OFFICER IDENTIFIED BELOW.
Your medical information is personal. We are committed to protecting your medical information. We create a record of the care and services you receive at this office. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office whether made by your personal physician or one of the office’s employees.
This Notice will tell you about the ways in which we may use and disclose your medical information. This Notice will also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.
This office is required by law to:
- Make sure that medical information that identifies you is kept private:
- Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the Notice that is currently in effect.
HOW THIS OFFICE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION:
The following describes the different ways that your medical information may be used or disclosed by this office. For clarification we have included some examples, not every possible use or disclosure is specifically mentioned. However, all of the ways we are permitted to use and disclose your medical information will fit within one of these general categories:
For Treatment: We may disclose medical information about you to doctors, nurses, technicians and other office personnel who are involved in providing you medical treatment.
For Payment: We may use and disclose medical information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, and/or your insurance company or third party. This includes information given to your health plan regarding a plan for treatment to obtain prior approval and determine eligibility to receive payment for such services.
For Health Care Operations: We may use and disclose medical information about you for office operations that are necessary to run our office and make sure that all of our patients receive quality care. Some examples of use include: for review of treatment and services and to evaluate the performance of our staff in caring for you. Our office utilizes a sign in sheet for patient name and email address which is removed after being filled out by our patient. We will address you by first and last name when moving you from any of our waiting rooms. If you do not wish to be contacted in this manner, please indicate this to our staff.
Appointment Reminders/Test Results: It is our practice to make reminder calls to patients that give the date of your appointment, the reason you are being seen and that your glasses or contact lenses are ready for pickup. This information may be left on your voice mail or answering machine. You may be contacted by telephone with test results or follow up treatment alternatives. Normal test results may be left on your answering machine or voice mail. If you do not wish to be contacted in this manner please indicate this to our staff.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Research: For teaching and case studies after it has been de-identified, in other words, not personally identifiable by your name, social security number or date of birth.
As Required by Law: Disclosure may be required by Workers’ Compensation and various public health statutes for required reporting of certain diseases, child abuse and neglect, domestic violence, adverse drug reactions, or as requested by subpoena.
To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to you, the public or another person’s health or safety. Disclosure will only be given to someone able to help prevent the threat.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may use your medical information to defend the office or to respond to a court order.
Law Enforcement: Information may be given if required by law when asked to do so by a law enforcement official.
Uses and Disclosures Requiring an Authorization:
Other uses and disclosures of your medical information not covered by this Notice of Privacy Practices will be made only with your written authorization. If authorization is provided in writing, you may revoke that authorization, in writing, at any time, except to the extent that we have acted in reliance of it. The following are examples of uses and disclosures requiring an authorization.
Marketing: We are required by law to receive your written authorization before we use or disclose your health information for marketing purposes, except if the communication is (a) face to face made by us to you; or (b) a promotional gift of nominal value we provide. If the marketing involves direct or indirect remuneration to us from a third party, the authorization must state that such remuneration is involved. If the marketing involves financial remuneration to us from a third party, that authorization must state that such remuneration is involved.
Sale of PHI: Under no circumstances will we sell our patient lists or your health information to a third party without your written authorization. Such authorization must state that the disclosure will result in remuneration to the covered entity.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:
Right to Inspect and Copy Medical Information: You must submit your request in writing to the HIPAA Privacy Officer. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect in certain very limited circumstances. If denied, you may request that the denial be reviewed. For information contact the HIPAA Privacy Officer. If your record is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or another individual or entity. We may charge you a reasonable cost-based fee limited to the labor costs associated with transmitting the electronic health record.
Right to Amend: If you feel that your medical information is incorrect or incomplete, you may submit a request with reason in writing to the HIPAA Privacy Officer for as long as the information is kept by this office. Requests not submitted in writing, or without reason to support request, may be denied. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us;
- Is not part of the medical information kept by this office;
- Is not part of the information which you would by permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures: You have the right to request a list of the disclosures this office has made of your medical information. We are not required to list certain disclosures such as those made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations. If these disclosures were made through an electronic health record, you have the right to request, beginning on dates established by law or regulation, an accounting for such disclosures that were made during the previous 3 years. You must submit your request in writing to the HIPAA Privacy Officer. Your request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure we make of your medical information. We are not required to agree to your request for a restriction, except as noted below. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We are required to agree to your request for a restriction if, except as otherwise required by law, the disclosure is to a health plan for purpose of carrying out payment or health care operations (and is not for purposes of carrying out treatment) and the medical information pertains solely to a health care item or service for which we have been paid out of pocket in full. Requests must be made in writing to the HIPAA Privacy Officer.
Right to Request Confidential Communications: For example, you can ask that we only contact you at work or by mail. Request must be made in writing to the HIPAA Privacy Officer. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice: Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our website address listed below. For a paper copy, contact the HIPAA Privacy Officer.
Right to Receive Notice of Discovery of a Breach of Unsecured Protected Health Information: We are required to notify you of any breach of unsecured protected health information concerning you following the discovery of the breach when required by regulation.
REVISIONS TO THIS NOTICE:
We reserve the right to revise this Notice. Any revised Notice will be effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of any revised Notice in this office with paper copies for you to take home, and at our website address listed below.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with this office or with the Secretary of the Department of Health and Human Services. To file a complaint with this office, contact IN WRITING:
Shawn Odil (248) 334-4931
Wilkinson Eye Center
44555 Woodward Ave Ste. 203
Pontiac, MI 48341
Our website address is www.wilkinsoneye.com
THIS OFFICE WILL NOT PENALIZE YOU IN ANY WAY FOR FILING A COMPLAINT.
