Effective date of notice: September17,2015
NOTICE OF PRIVACY PRACTICES
Amy Jankowski, O.D., Kaelyn Zaporski, O.D., Amanda Kopczyk, O.D.
Ph: 4147275888 Fax: 4147275889 firstname.lastname@example.org
325 E. Chicago St. Milwaukee, WI 53202
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TOTHIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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; filling of your eyeglass or contact prescription by labs or vendors; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services. Examples of how we use or disclose health information for payment purposes are: asking you about insurance, or other sources of payment; preparing and sending bills or claims; collecting unpaid amounts (either ourselves or through a collection agency, attorney or bank). If a check is returned from a bank for insufficient funds Metro eye will charge any bank fees plus an additional $25 fee. “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 and business planning.
We routinely use your health information inside or outside our office for these purposes without any special permission. If we need to disclose your health information outside of our office in order to obtain copies of your health information from another professional we will ask 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 will apply to us; some may never come up at our office at all. Such uses or disclosures are:
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.
Although you have indicated a preferred method of communication on your consent form, we may use one of the other methods of communication you have provided us with to communicate with you if necessary. We sometimes use email to correspond with patients as a convenience. However, these emails are not encrypted and could theoretically be intercepted. Unless you object, you are giving us permission to correspond with you via email in spite of this potential risk.
A Continuity of Care (CCD) is a document which summarizes information obtained by your health care providers in a format that can be shared electronically through a highly secure web portal. This information will be shared only with your specified health care providers. The information included in a CCD is current medications, drug allergies and diagnoses. A CCD may be generated for all patient encounters in order to provide a high quality of care by allowing an efficient exchange of vital information between your health care providers. Once your CCD is available you will receive notification and instruction of how to access your CCD at the email address you provided to Metro Eye. You may opt out of receiving this notification by alerting a member of the Metro Eye staff of your wish to decline the electronic CCD at the time you check in for your appointment. Unless otherwise informed, you are giving Metro Eye consent to send notification of this document to you via email.
We may call, email, send a postcard or text to remind you of scheduled or due appointments, or that it is time to make an 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, email you a reminder, and/or leave you a reminder message on your 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. 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.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can:
BREACH OF INFORMATION
We follow HIPAA guidelines very closely, however, we will inform you if Metro Eye discovers a breach of protected health information by our office or a covered entity. Our office will contact the individual(s) affected by mail or encrypted email (if email address has been provided.) We will use every effort to contact individuals as set forth by the US Department of Health and Human Services. These individual notifications will be provided without unreasonable delay and no later than 60 days following the discovery. If the breach affects more than 500 individuals we will notify the Secretary of the HHS immediately or if fewer than 500 individuals are affected we will notify the Secretary on an annual basis.
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. 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.
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.
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 Please sign the on the front of the welcome form on this clipboard