Privacy Notice
Effective date of notice: April 15, 2003
NOTICE OF PRIVACY PRACTICES
Charles H. Rutan, O.D.
250 Blackman St.
Clinton, IN 47842
Phone: (765)832-0712
Fax: (765)832-9730
Advantageeyecare.org
Contact: Kim Evans
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 options. 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. Show you low vision aids referring you to another doctor or clinic for eye care or low vision aids or service 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 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.
We will ask for special written permission in the following situations: transferring records.
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:
When a state or federal law mandates that certain health information is 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 on victims of suspected abuse, neglect domestic violence.
Uses and disclosures for health oversight activity, such as, for the licensing of doctor for audits by Medicare or Medicaid or for investigation of possible violations for 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 president or high-ranking government officials for lawful national intelligence activity for military purposes or for the evaluation and health of members of the Foreign Service.
Disclosures of de-identified information.
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, 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 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. Unless you tell us otherwise, we 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.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written authorization form. Federal law determines the content of an authorization form. 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 the 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 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 personal 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 60 days if the information is stored off-site). You may have to pay for photocopies 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 60-day extension of the 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 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
Get a list of 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 on 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, E-mail shown at the beginning of this Notice.
Get additional paper copies of this Notice of Privacy Practice upon request. If it does not matter whether you get one electronically or in paper form. If you want additional copies, send a written request to the office contact person at the address, fax, or E-mail shown at the beginning of this Notice.
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, 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.
NOTICE OF PRIVACY PRACTICES
Charles H. Rutan, O.D.
250 Blackman St.
Clinton, IN 47842
Phone: (765)832-0712
Fax: (765)832-9730
Advantageeyecare.org
Contact: Kim Evans
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 options. 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. Show you low vision aids referring you to another doctor or clinic for eye care or low vision aids or service 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 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.
We will ask for special written permission in the following situations: transferring records.
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:
When a state or federal law mandates that certain health information is 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 on victims of suspected abuse, neglect domestic violence.
Uses and disclosures for health oversight activity, such as, for the licensing of doctor for audits by Medicare or Medicaid or for investigation of possible violations for 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 president or high-ranking government officials for lawful national intelligence activity for military purposes or for the evaluation and health of members of the Foreign Service.
Disclosures of de-identified information.
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, 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 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. Unless you tell us otherwise, we 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.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written authorization form. Federal law determines the content of an authorization form. 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 the 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 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 personal 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 60 days if the information is stored off-site). You may have to pay for photocopies 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 60-day extension of the 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 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
Get a list of 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 on 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, E-mail shown at the beginning of this Notice.
Get additional paper copies of this Notice of Privacy Practice upon request. If it does not matter whether you get one electronically or in paper form. If you want additional copies, send a written request to the office contact person at the address, fax, or E-mail shown at the beginning of this Notice.
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, 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.