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Notice
of Privacy Practices
Drs. Dexter,
Stegen, Reed and Baylus, Optometrists
200 South
Main St.
West Lebanon, NH 03784
(603) 298-8064
(603) 298-7898 FAX
www.pro-optical.com
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 your health 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 will ask you for special written permission.
We will ask for
special written permission in the following
situations: ____________.
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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;
- Disclosures
to governmental authorities abut 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 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 disclosures
to prevent a serious threat to health
or safety;
- Uses or disclosures
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 byproduct
of permitted uses or disclosures;
- Disclosures
to "business associates" who
perform health care operations for us
and who commit to respect the privacy
of your health information;
- [specify other
uses and disclosures affected by state
law].
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.
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Appointment Reminders
We may call or
write to remind you 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
form" 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 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. Send them
to the office contact person named at the
beginning of this Notice.
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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 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 us for any
extra cost. If 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 asking us (or sixty days if the information
is stored off-site). You may have to pay
for photo copies 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 photo copies
if we send you a written notice of the
extension. If you want to review or get
photo copies of your health information,
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 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 office
contact person at the address, fax or
E-mail shown at the beginning of this
Notice.
- Get 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, send a written request
to the office contact person at the address,
fax or E-mail shown at the beginning of
this Notice.
- Get additional
paper copies of this Notice of Privacy
Practices 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 E-mail shown at the beginning of
this Notice.
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Our Notice of
Privacy Practices
By law, we must
abide by the terms of this Notice of Privacy
Practices 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
Notice of Privacy Practices, 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 think
that we have not properly respected the
privacy of your health information, you
are free to complain to us or 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 want
to complain to us, send a written complaint
to the office contact person at the address,
fax or E-mail shown at the beginning of
this Notice. If you prefer, you can discuss
your complaint in person or by phone.
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.
NF/02
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Acknowledgment
of Receipt
I acknowledge
that I have received a copy of _________________________
O.D., Notice of Privacy practices. Date
_______________
Patient Name
_________________________________________
Signature
____________________________________________
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