Effective date of notice: 07/20/12
NOTICE OF PRIVACY PRACTICES
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.
THE RETINAL INSTITUTE respects its legal obligation to keep health information that identifies you as private. THE RETINAL INSTITUTE is obligated by law to give you notice of its privacy practices. This Notice describes how THE RETINAL INSTITUTE protects your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why THE RETINAL INSTITUTE uses or discloses your health information is for treatment, payment or health care operations. Examples of how THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE has to do in order to run its office. Examples of how THE RETINAL INSTITUTE 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.
THE RETINAL INSTITUTE routinely uses your health information inside its office for these purposes without any special permission. If THE RETINAL INSTITUTE needs to disclose your health information outside of its office for these reasons, it usually will not ask you for special written permission.
THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE to use or disclose your health information without your permission. Not all of these situations will apply to THE RETINAL INSTITUTE; some may never come up at THE RETINAL INSTITUTE 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;
- 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, THE RETINAL INSTITUTE will also share relevant information about your care with your family or friends who are helping you with your eye care. APPOINTMENT REMINDERS
THE RETINAL INSTITUTE may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. THE RETINAL INSTITUTE may also call or write to notify you of other treatments or services available at its office that may help you. Unless you tell THE RETINAL INSTITUTE otherwise, THE RETINAL INSTITUTE 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
THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE privacy officer at the address shown above. OTHER USES AND DISCLOSURES
THE RETINAL INSTITUTE 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, THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE to send your information to someone else. Typically, in this situation you will give THE RETINAL INSTITUTE a properly completed authorization.
If THE RETINAL INSTITUTE 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, THE RETINAL INSTITUTE cannot make the use or disclosure. If you do sign an authorization, you may revoke it at any time unless THE RETINAL INSTITUTE has already acted in reliance upon it. Revocations must be in writing. Send them to the THE RETINAL INSTITUTE 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:
OUR NOTICE OF PRIVACY PRACTICES
- ask THE RETINAL INSTITUTE to restrict its uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. THE RETINAL INSTITUTE does not have to agree to this, but if it agrees, THE RETINAL INSTITUTE must honor the restrictions that you want. To ask for a restriction, send a written request to the THE RETINAL INSTITUTE privacy officer at the address shown above.
- You can, however, request that THE RETINAL INSTITUTE restrict the disclosure of your PHI to a health plan if you have paid out-of-pocket fully and THE RETINAL INSTITUTE must honor it.
- ask THE RETINAL INSTITUTE 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. THE RETINAL INSTITUTE will accommodate these requests if they are reasonable. If you want to ask for confidential communications, send a written request to the THE RETINAL INSTITUTE privacy officer at the address shown above.
- ask to see or to get photocopies of your health information. By law, there are a few limited situations in which THE RETINAL INSTITUTE 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 60 days if the information is stored off site). You may have to pay for photocopies in advance. If THE RETINAL INSTITUTE 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, THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE privacy officer at the address shown above.
- ask THE RETINAL INSTITUTE to amend your health information if you think it is incorrect or incomplete. If THE RETINAL INSTITUTE agrees, it will amend the information within 60 days from date requested. THE RETINAL INSTITUTE will send the corrected information to persons whom it knows received the wrong information, and others whom you specify. If THE RETINAL INSTITUTE does not agree, you can write a statement of your position, and THE RETINAL INSTITUTE will include it with your health information along with any rebuttal it may write. Once your statement of position and/or THE RETINAL INSTITUTE’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, THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE privacy officer shown above.
- get a list of the disclosures THE RETINAL INSTITUTE 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. THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE notifies you of the extension in writing. If you want a list, send a written request to the THE RETINAL INSTITUTE 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.
By law, THE RETINAL INSTITUTE must abide by the terms of this Notice of Privacy Practices until it chooses to change it. THE RETINAL INSTITUTE reserves the right to change this notice at any time as allowed by law. If THE RETINAL INSTITUTE changes this Notice, the new privacy practices will apply to your health information that it already has, as well as to such information that THE RETINAL INSTITUTE may generate in the future. If THE RETINAL INSTITUTE 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. COMPLAINTS
If you think THE RETINAL INSTITUTE has not properly respected the privacy of your health information, you are free to complain to THE RETINAL INSTITUTE or the U.S. Department of Health and Human Services Office for Civil Rights. THE RETINAL INSTITUTE will not retaliate against you if you make a complaint. If you want to complain to THE RETINAL INSTITUTE, send a written complaint to the THE RETINAL INSTITUTE 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 THE RETINAL INSTITUTE’s privacy practices, write the THE RETINAL INSTITUTE privacy officer at the address shown at the beginning of this Notice.