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Effective date of notice:
April 14, 2003
Notice of Privacy Practices
Dakota EyeCare Associates
1540 Humboldt Ave.
West St. Paul, MN 55118
651-457-2020
Mark J. Hennen OD
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| 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. |
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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 of low
vision aids or services or getting copies of
your health information from another
professional that you may have seen before us.
Example 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 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 an from the
FDA regarding drugs or medical devices;
- Disclosure to governmental authorities
about 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 violation of health care laws
- Disclosures for judicial and
administrative proceedings, such as in
response to subpoenas or orders of 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 at our office; or to report a
crime that happened somewhere else;
- Disclosure to a medical examiner to
identify a dead person or to determine the
cause of death; or to funeral directors to
aid in burial; or to organizations that
handle organ or tissue donations
- Uses or disclosures for health related
research
- Uses and disclosure to prevent a serious
threat to health or safety;
- Uses or disclosure for specialized
government functions, such as for the
protection of the president or high ranking
government officials; for lawful national
intelligence activities; for military
purposes; or for the evaluation and health
of members of the foreign service;
- Disclosures of de-identified information
- 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
disclosure;
- 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 reminder of
scheduled appointments, or 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.
Other Uses And Disclosures
We will not make any other uses or
disclosures of your health information unless
you sign a written “authorization form”. The
content of an “authorization from” is determined
by federal law. Sometimes, we may initiate the
authorization process if the use or disclosure
is our idea. Sometimes, you may initiate the
process if it’s your idea 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 no 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 any time unless we
have already acted in reliance upon it.
Revocations must be in writing. Send them to the
office contact person named at the beginning of
this Notice.
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
hone the restriction that you want. To ask
for a restriction, send a written request to
the office contact person at the address,
fax or E-mail shown at the beginning of this
Notice.
- Ask us to communicate with you in a
confidential way, such as by phoning you at
work rather than at home, by mailing health
information to a different address, or by
using E-mail to your personal E-mail
address. We will accommodate these requests
if they are reasonable, and if you pay the
extra cost. I you want to ask for
confidential communications, send a written
request to the office contact person at the
address, fax or E-mail shown at the
beginning of this Notice.
- Ask to see or to get photocopies of your
health information. By law, there are a few
limited situations in which we can refuse to
permit access or copying. For the most part
however, you will be able to review or have
a copy of your health information within 30
days of a asking us. You may have to pay for
photocopies is advance. If we deny your
request, we will send you a written
explanation, and instructions about how to
get an impartial review or 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. I you want
to review or get photocopies of your health
information, send a written request to the
office contact person at the address, fax or
Email shown at the beginning of this notice.
- Ask us to amend your health information
if you think that it is correct or
incomplete. I 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 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 fro
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 to the office contact person at the
address, fax or Email shown at the beginning
of this notice.
- Get a list of the disclosure that we
have made of your health information within
the last six years (or less if you want). By
law the list will not include; disclosures
for purposes to treatment, payment or health
care operation; disclosures with your
authorization; incidental disclosures;
disclosure required by law’ and some other
limited disclosures. You are entitled to one
such list per year without charge. I 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, send a written request to the office
contact person at the address, fax or Email
shown at the beginning of this notice.
- Get additional paper copies of this NPP
upon request. It does not matter whether you
got one electronically or in paper form
already. If you want additional paper
copies, send a written request to the office
contact person at the address, fax or Email
shown at the beginning of this notice.
Our Notice Of Privacy Practices
By law, we must abide by the terms of this NPP
until we choose to change it. We reserve the
right to change this notice at any time as
allowed by law. If we change this notice 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, have copies available
in our office, and post it on our web site.
Complaints
If you thing that we have not properly respected
the privacy of you health information you are
free to complain to us or the U.S. Department of
Health and Human Services. We will not retaliate
against you if you make a complaint. I you want
to complain to us, send a written request to the
office contact person at the address, fax or
Email shown at the beginning of this notice.
For More Information
If you want more information about our privacy
practices call or visit the office contact
person at the address or phone number shown at
the beginning of this Notice.
Acknowledgement of Receipt
I acknowledge that I received a copy of
Dakota EyeCare’s Notice of Privacy Practice
Patient
Name________________________________________________
Signature____________________________________Date____________
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