CLEAR LAKE OPTOMETRY
Karen
P. Anderson, O.D.
14
North 8th Street
(641)
357-2020
Fax:
(641) 357-7149
Email:
[email protected]
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT
TO US.
Note: If you have questions about this
notice, please contact the Privacy Officer at Clear Lake Optometry.
WHO WILL
FOLLOW THIS NOTICE:
This notice describes the privacy
practices of Dr. Karen P. Anderson, dba, Clear Lake Optometry. Our physician and staff may have access to
information in your chart for treatment, payment and health care operations,
which are described below, and may use and disclose information as described in
this Notice. This Notice also applies to
any volunteer or trainee we allow to help you while seeking services from us.
OUR PLEDGE
REGARDING THE PRIVACY OF YOUR MEDICAL
INFORMATION:
Your medical information includes
information about your physical and mental health. We understand that information about your
physical and mental health is personal.
We are committed to protecting medical information about you. We create a record of the care and services
you receive from us. We need this record to provide you with quality care and
to comply with certain legal requirements.
This notice applies to any and all of the records of your care generated
by us.
This notice will tell you about the
ways in which we may use and disclose medical information about you. We also describe your rights and certain
obligations we have regarding the use and disclosure of medical
information.
We reserve the right to revise or amend
our notice of privacy practices without additional notice to you. Any revision or amendment to this notice will
be effective for all of your records our practice has created or maintained in
the past, and for any of your records we may create or maintain in the future.
We will post a copy of our current notice in our offices in a prominent place
and will post the notice on our Website.
OUR OBLIGATIONS TO YOU
We
are required by law to:
·
make sure that medical information that identifies you is
kept private except as otherwise provided by state or federal law;
·
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 WE MAY USE
AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The following categories describe
different ways that we may use and disclose medical information. For each category of uses or disclosures we
will explain what we mean and try to give some examples. Not every use or disclosure in a category
will be listed. This notice covers
treatment, payment, and what are called health care operations, as discussed
below. It also covers other uses and
disclosures for which a consent or authorization are not necessary. Where Iowa law is more protective of your
medical information, we will follow state law, as explained below.
For Treatment. We may use medical information about you to
provide you with medical treatment or services without consent or authorization
unless otherwise required by applicable state law. We may disclose medical information about you
to doctors, nurses, medical students, pharmacists, laboratories, or other
health care providers who are involved in taking care of you whether or not
they are affiliated with us. For
example, we may disclose medical information concerning you to [hospitals, family practice groups,
dispensaries, pharmacies, and/or other providers you may share information
with] as well as to any other entity that has provided or will provide care
to you. We will disclose any mental
health information, including psychotherapy notes, AIDS or HIV-related
information, or drug treatment information, that we may have about you only
with written authorization as required by Iowa law, HIPAA and other federal
regulations.
During the course of your treatment, we
may refer you to other health care providers such as independent laboratories
with which you may not have direct patient contact. These providers are called "indirect
treatment providers."
"Indirect treatment providers" are required to comply with the
privacy requirements of state and federal law and keep your medical information
confidential.
For Payment. We may use and disclose medical information
about you without consent or authorization so that the treatment and services
you receive from us 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 health plan information about treatment
received so your health plan will pay us or reimburse you for the
treatment. We may also tell your health
plan or insurance company about a treatment you are going to receive to obtain
prior approval or to determine whether it will cover the treatment.
For Health Care Operations. We may use and disclose medical information
about you without consent or authorization for "health care
operations". These uses and
disclosures are necessary to operate our practice and make sure that all of our
patients receive quality care. For
example, we may use medical information or mental health treatment information
to review our treatment and services and to evaluate the performance of our
staff in caring for you. We may also
disclose your protected health information to doctors, nurses, medical students
and other employees or consultants for review and learning purposes.
Appointment Reminders. We may use and disclose medical information
to contact you by mail or phone to remind you that you have an appointment for
treatment, unless you tell us otherwise in writing.
Treatment Alternatives. We may use and disclose medical information
to tell you about or recommend possible treatment options or alternatives that
may be of interest to you. However, we will not use or disclose medical
information to market other products and services, either ours or those of
third parties, without your authorization.
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.
Individuals Involved in Your Care or
Payment for Your Care. We may release
medical information [including mental
health information], about you to a family member who is involved in your
medical care without consent or authorization.
We may also give medical information, including prescription information
or information concerning your appointments to friends who are involved in your
care. We may also give such information
to someone who helps 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 and location.
As Required By Law. We will disclose medical information about
you when required to do so by federal, state or local law without your consent
or authorization.
To Avert a Serious Threat to Health or
Safety. We may disclose medical 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. Any disclosure, however, would only be to
someone able to help prevent the threat.
To Business Associates. Dr.
Karen Anderson, from time to time will hire consultants called
"business associates," who render services to us. We may disclose your medical information to
such business associates without your consent or authorization. Business associates are required to maintain
and comply with the privacy requirements of state and federal law and keep your
medical information confidential.
Examples of "business
associates" are accounting firms that we hire to perform audits of billing
and payment information, and computer software vendors who assist us in
maintaining and processing medical information.
Military and Veterans. If you are a member of the armed forces, we
may release medical information about you as required by military command
authorities. We may also release medical
information about foreign military personnel to the appropriate foreign
military authority.
Workers Compensation. We may release medical information about you
for workers compensation or similar programs without consent or authorization. These programs provide benefits for
work-related injuries or illnesses. For
example, if you are injured on the job, we may release information regarding
that specific injury.
Public
Health Risks. We may disclose
medical information about you for public health activities without your consent
or authorization. These activities
generally include the following:
·
to prevent or control disease, injury or disability;
·
to report reactions to medications or problems with
products;
·
to notify people of recalls of products they may be using;
·
to notify a person who may have been exposed to a disease or
may be at risk for contracting or spreading a disease or condition;
·
to notify the appropriate government authority if we believe
a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
Health Oversight Activities. We may disclose medical information to a
health oversight agency, such as the Department of Health and Human Services,
for activities authorized by law. These
oversight activities include, for example, audits, investigations, inspections,
and licensure. These activities are necessary
for the government to monitor the health care system, government programs, and
compliance with civil rights laws.
Lawsuits and Administrative
Proceedings. If you are involved
in a lawsuit or dispute as a party, we may disclose medical information about
you in response to a court or administrative order. We may also disclose medical information
about you in response to a subpoena, discovery request, or other lawful process
by someone else involved in the dispute.
Similarly we may disclose medical information about you in proceedings
where you are not a party, but only if efforts have been made to tell you or
your attorney about the request or to obtain an order protecting the
information requested. In addition, we
may disclose medical information, including mental health treatment information,
to the opposing party in any lawsuit or administrative proceeding where you
have put your physical or mental condition at issue.
Law Enforcement. We may release medical information if asked
to do so by a law enforcement official:
·
in response to a court order, subpoena, warrant, summons or
similar process;
·
to identify or locate a suspect, fugitive, material witness,
or missing person;
·
about the victim of a crime if, under certain limited
circumstances, we are unable to obtain the persons agreement;
·
about a death we believe may be the result of criminal
conduct;
·
about criminal conduct at Abbe Inc.Medical
Associates Clinic; and
·
in emergency circumstances to report a crime; the location
of the crime or victims; or the identity,
description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral
Directors. We may release medical information including
mental health information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death.
National Security and Intelligence
Activities. We may release medical information about you
to authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective Services for the President
and Others. We may disclose
medical information about you to authorized federal officials so they may
provide protection to the President, other authorized persons or foreign heads
of state or conduct special investigations.
Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may release
medical information about you to the correctional institution or law
enforcement official. This release would
be necessary (1) for the institution to provide you with health care; (2) to
protect your health and safety or the health and safety of others; or (3) for
the safety and security of the correctional institution.
YOUR
RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding
medical information we maintain about you:
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.
If you wish to be provided a copy of
medical information that may be used to make decisions about you, you must
submit your request in writing to the Privacy Officer. If you
request a copy of the information, we will charge a reasonable fee of $25.00
for the costs of copying, mailing and or other supplies associated with your
request.
We may deny your request to inspect
and/or obtain a copy in certain very limited circumstances. If you are denied access to medical
information, you may request that the denial be reviewed. Another licensed health care professional
chosen by us will review your request and the denial. The person conducting the review will not be
the person who denied your request. We
will comply with the outcome of the review.
Right to Request an Amendment. If you feel that medical 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 for as long as the information is kept by or for us.
To request an amendment, your request
must be made in writing and submitted to the Privacy Officer. In
addition, you must provide a reason that supports your request.
We may deny your request for an
amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your
request if you ask us to amend information that:
·
Was not created by us, unless the person or entity that
created the information is no longer available to make that amendment;
·
Is not part of the medical information kept by us
·
Is not part of the information which you would be permitted
to inspect and copy; or
·
Is accurate and complete.
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.
To request this list or accounting of
disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which
may not be longer than six years starting with April 15, 2003. Your request will be provided to you on
paper. 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 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 may request that your spouse or child who is involved
in your care not receive certain information about your condition.
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.
To request restrictions, you must make
your request in writing to the Privacy Officer. In your request, you must tell us (1) what
information you want to limit; (2) whether you want to limit our use,
disclosure or both; and (3) to whom you want the limits to apply, for example,
disclosures to your spouse.
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 must make your request in writing to the Privacy Officer. We will not ask 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 this
notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at
our web site, www.cloptometry.com.
COMPLAINTS. If you believe your privacy rights have been
violated, you may file a complaint with us or with the Secretary of the Department
of Health and Human Services. To file a
complaint with us, submit your complaint in writing to the Privacy Officer. 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 as set out in an authorization signed by you. 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. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we are
required to retain our records of the care that we provided to you.
Karen P. Anderson, O.D.
14 North 8th Street
(641) 357-2020
Fax: (641) 357-7149
Email: [email protected]
I acknowledge that on ___ day of ,200 , I received a copy of Dr.
Karen P. Andersons Notice of
Privacy Practices.
Dated this _____ day of , 200__.
or
Legal Guardian or Personal Representative
[or other relationship]