Effective date of notice: 07/12/13
NOTICE OF PRIVACY PRACTICE
The Retinal Institute
P.O. Box 549
Wabash, IN 46992
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.
TRI respects its legal obligation to keep health information that identifies you as private. TRI is obligated by law to give you notice of its privacy practices. This Notice describes how TRI protects your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why TRI uses or discloses your health information is for treatment, payment or health care operations. Examples of how TRI uses or discloses 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 TRI uses or discloses your health information for payment purposes are: asking you about your health care plans, or other sources of payment; preparing and sending bills or claims, or collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that TRI has to do in order to run its office. Examples of how TRI uses or discloses 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.
TRI routinely uses your health information inside its office for these purposes without any special permission. If TRI needs to disclose your health information outside of its office for these reasons, it usually will not ask you for special written permission.
TRI will ask for special written permission in the following situations; contact lens prescriptions; access to medical records by the patient, access to medical records of a minor, mental health records, communicable diseases records, alcohol and drug abuse records, and health records to accident and sickness insurance companies.
USES & DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires TRI to use or disclose your health information without your permission. Not all of these situations will apply to TRI; some may never come up at TRI at all. Such uses or disclosures are:
- when a state of 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 for notices to and from federal Food and Drug administration regarding drugs or medical devices, coordinating care in event of a disaster through Disaster Relief Organizations
- disclosures 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 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; 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-identification 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 disclosures;
- 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, TRI will also share relevant information about your care with your family or friends who are helping you with your eye care.
TRI may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. TRI may also call or write to notify you of other treatments or services available at its office that may help you. Unless you tell TRI otherwise, TRI will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
FUNDRAISING & MARKETING
TRI may use or disclose to a business associate or to an institutionally related foundation, demographic information and dates of care relating to you without your authorization. Upon receiving any written fundraising communication, you may elect to “opt out” of any further such communication. Any such elect shall be treated as a revocation of authorization. To make such election send a written request to the TRI privacy officer at the address shown above. Your authorization will be obtained prior to TRI sending any marketing material to you that will result in financial remuneration to TRI.
OTHER USES AND DISCLOSURES
TRI will not make any other uses or disclosures of your health information unless you sign a written authorization. The content of the authorization is determined by federal law. Sometimes, TRI may initiate the authorization process if the use or disclosure is its idea. Sometimes, you may initiate the process if it is your idea for TRI to send your information to someone else. Typically, in this situation you will give TRI a properly completed authorization.
If TRI initiates the process and asks you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, TRI cannot make the use or disclosure. If you do sign an authorization, you may revoke it at any time unless TRI has already acted in reliance upon it. Revocations must be in writing. Send them to the TRI privacy officer at the address shown above.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
- ask TRI to restrict its uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. TRI does not have to agree to this, but if it agrees, TRI must honor the restrictions that you want. To ask for a restriction, send a written request to the TRI privacy officer at the address shown above.
- You can, however, request that TRI restrict the disclosure of your PHI to a health plan if you have paid out-of-pocket fully and TRI must honor it.
- Have access to an electronic copy of your healthcare records when PHI is maintained in electronic format.
- ask TRI to communicate with you in a confidential way, such as by phoning you at work rather than at home or by mailing health information to a different address. TRI will accommodate these requests if they are reasonable. If you want to ask for confidential communications, send a written request to the TRI privacy officer at the address shown above.
- Be notified if a breach of confidentiality occurs that involves your PHI.
- ask to see or to get photocopies of your health information. By law, there are a few limited situations in which TRI 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. You may have to pay for photocopies in advance. If TRI denies your request, it will send you a written explanation and instructions about how to get an impartial review of its denial if one is legally available. By law, TRI can have one 30-day extension of time for us to give you access or photocopies if we send you a written notice of extension. If you want to review or get photocopies of your health information, send a written request to the TRI privacy officer at the address shown above.
- ask TRI to amend your health information if you think it is incorrect or incomplete. If TRI agrees, it will amend the information within 60 days from date requested. TRI will send the corrected information to persons whom it knows received the wrong information, and others whom you specify. If TRI does not agree, you can write a statement of your position, and TRI will include it with your health information along with any rebuttal it may write. Once your statement of position and/or TRI’s rebuttal is included in your health information, it will send it along whenever it makes a permitted disclosure of your health information. By law, TRI can have one 30-day extension to consider a request for amendment if it notifies you in writing of the extension. If you want to amend your health information, send a written request, which includes your reasons for the amendment, to the TRI privacy officer shown above.
- get a list of the disclosures TRI has made of your health information within the past six years (or a shorter period). By law, the list will not include: disclosures for purposes of treatment, payment of 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. TRI will usually respond to your request within 30 days of receiving it, but by law we can have one 30-day extension of time if TRI notifies you of the extension in writing. If you want a list, send a written request to the TRI privacy officer at the address shown above.
- get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you previously received one. If you want additional paper copies, send a written request to the privacy officer at the address shown above.
OUR NOTICE OF PRIVACY PRACTICES
By law, TRI must abide by the terms of this Notice of Privacy Practices until it chooses to change it. TRI reserves the right to change this notice at any time as allowed by law. If TRI changes this Notice, the new privacy practices will apply to your health information that it already has, as well as to such information that TRI may generate in the future. If TRI changes its Notice of Privacy Practices, it will post the new notice in its office, have copies available in its office, and post it on its Web site if applicable.
If you think TRI has not properly respected the privacy of your health information, you are free to complain to TRI or the U.S. Department of Health and Human Services Office for Civil Rights. TRI will not retaliate against you if you make a complaint. If you want to complain to TRI, send a written complaint to the TRI privacy officer at the address shown above. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about TRI’s privacy practices, write the TRI privacy officer at the address shown at the beginning of this Notice.