Order Contacts Ohio Eye Doctors

NOTICE OF PRIVACY PRACTICES

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.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE OR ABOUT OUR PRIVACY PRACTICES, PLEASE CONTACT OUR PRIVACY OFFICER, Mike Graham , AT: Ohio Eye Associates, Inc. 466 S. Trimble Rd. Mansfield, Ohio 44906-3482 419/756-8000. Effective Date of this Notice: April 14, 2003. This Notice of Privacy Practices (called “Notice”) describes how we may use and disclosure your Protected Health Information (called “PHI”). We must abide by this Notice when we use your PHI in our office or when we disclose or share your PHI with others outside of our office. We may change this Notice at any time. We will keep a copy of our current Notice posted in the waiting room [and on our website at {www.ohioeyeassociates.com}]. If we revise the Notice, the new Notice will apply to all PHI that we have in our possession at that time or PHI that we will come into the possession of in the future. If you would like a copy of the revised Notice, you may request one by phone, by letter, or in person the next time that you come into the office.

WHY WE ARE GIVING YOU THIS NOTICE: Congress passed a law called the Health Insurance Portability and Accountability Act in 1996. This law is sometimes called HIPAA. The HIPAA law requires us to maintain the privacy of your PHI. We are also required to provide you with this Notice that explains our responsibilities in using and disclosing your PHI and also tells you what your rights are and how to complain if you think that we violated your privacy.

WHAT IS PROTECTED HEALTH INFORMATION (“PHI”)?

Protected Health Information or PHI is information that we have about you that is included in your medical and billing records. This information may identify you and may describe, or is related to, your past, present, or future physical and mental health. Every time you visit our office we make a medical record of the visit. We also make a billing record of your current name, address, and phone number as well as your health insurance information. We use the information in your medical record to provide health treatment to you and the information in your medical and billing records to obtain payment for that treatment. This medical and billing record information is called Protected Health Information or PHI.

HOW WE WILL USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. In this Notice, the word “use” means to review, consult, read, update, and study your PHI so that we can provide health care to you to assure that we are caring for you in the best way that we can and to perform other activities permitted or required by law. The word “disclose” in this Notice means that we are providing your PHI to someone outside of our practice so that he or she can provide care for you, understand your health condition in order to explain it to you, learn more about your particular health condition or so that we can get paid for providing health care to you and to perform other activities permitted or required by law. These are the activities where we may use and disclose your PHI:

1.

For Treatment.

One of the most common reasons that we use or disclose your PHI is to provide health care treatment to you. We will use the medical and health information in your medical record to provide treatment to you. We may disclose your PHI to other health care providers, such as doctors, nurses and laboratory technicians, medical students, or hospital personnel who are involved in taking care of you at the hospital or in other doctor’s offices, so that they can provide health care treatment to you. An example of how we use your PHI in our office to provide you with health care treatment is when a doctor in our office reviews the results of blood work that you had so that he can provide treatment for you. An example of how we disclose your PHI is when we send a copy of your medical record to another doctor who is a specialist that we referred you to for treatment of a specific problem.

2.

For Payment.

We may use or disclose your PHI so that we can obtain payment for the health care services that we provide for you. For example, we may send a statement to you so that we can receive payment for your health care treatment. If someone else pays for your health care treatment, such as an insurance company or Medicare or Medicaid, we may send your PHI to them in order to receive payment for our health care services to you. We may also send your PHI to your health insurance provider in order to receive approval in advance for treatment that we would like to provide to you.

3.

For Health Care Operations.

We may use or disclose your PHI for our health care operations. Health care operations are the business operations of our office that have to do with maintaining the office as a business and assuring that we provide quality care to our patients. For example, we may share your PHI with other doctors and health care professionals in order to review the care that was provided to you so that we can be certain that we are providing you with the best health care possible.

4.

For Emergency Treatment.

We may use or disclose your PHI to provide you with emergency treatment. If this happens, we will attempt to obtain your consent for the PHI that we used or disclosed in order for you to obtain this emergency treatment as soon after the emergency as possible.

5.

To Family and Close Friends Involved in Your Care.

We may disclose your PHI to a family member or a close friend if those persons accompany you while you are receiving health care services or if we determine that it is in your best interest so that we can provide you with the best health care possible. We may also disclose your PHI to a family member or someone else who helps pay for your health care treatment. If you do not want us to disclose your PHI to family members or close friends, please tell us and we will honor your request unless we determine that it is not in your best interest to do so.

6.

Appointments and Reminders.

We may use and/or disclose your PHI to contact you by phone or by mail as a reminder that you have an appointment, to share results of a test or procedure, or to discuss a health issue with you. We may leave our name and phone number on an answering machine, voice mail, or with someone who answers the phone. We may ask you to sign into our office on a sign-in sheet so that we can keep track of who is waiting in the office to be seen and who you are waiting to see and we may call out your name when it is time for you to be seen by the doctor. If you do not want us to use or disclose your PHI in this way, please talk with our Privacy Officer about completing an “Alternative Communication Request” form or a “Request for Restriction Of Use or Disclosure of PHI” form.

7.

Marketing and Fund-Raising.

We may use and/or disclose your PHI for marketing or fund-raising purposes, such as to tell you about alternative health care services or treatment options that may be of interest to you or to contact you as part of a fund-raising effort.

8.

Health-Related Benefits and Services.

We may use and/or disclose your PHI to tell you about health-related benefits or new products or services that may be of interest to you.

9.

For Communication Purposes.

We may use and/or disclose your PHI to a third party if we have difficulty communicating with you.

10.

Business Associates.

We may disclose protected health information to employees in other businesses who assist us in your health care treatment. When we use business associates, we require that they agree to protect and safeguard your PHI before we allow them to be our business associates and before we disclose your PHI to them.

11.

For Research.

We may use or disclose your PHI for our own research or for research purposes of other organizations. We will disclose your PHI to others for research purposes, without your consent or authorization, only if their research proposal has been approved by an established, authorized review board and the researchers have established procedures to ensure the privacy of your PHI.

12.

Military Activities and National Security.

We may disclose your PHI to military personnel for the purposes of certain military activities, for intelligence purposes, or for national security.

13.

Worker’s Compensation.

We may disclose your PHI to the Bureau of Workers’ Compensation (“BWC”) or other similar legally established programs.

14.

Funeral Directors, Coroners and Organ Donation Facilities.

We may disclose your PHI to funeral directors, coroners or medical examiners so that they can identify you, determine why you died, or perform some other activity permitted or required by law. We may also disclose your PHI to a facility where you donated organs.

15.

Correctional Institution.

We may disclose PHI about you to individuals in correctional facilities, such as a prison official who requests information about your health conditions so that you can receive appropriate health care if you were to go to jail.

16.

As Required By Law.

We may disclose PHI about you when we are required to do so by federal, state or local law. If a law requires that we disclose your PHI, we will do so only to the extent required by the law. Federal law permits and/or requires us to disclose your PHI to agencies that perform health care oversight, public health activities, workers compensation, food and drug administration, or to report suspected child abuse, neglect, or domestic violence and similar legally regulated activities.

17.

Lawsuits, Court and Administrative Orders.

If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order.

18.

Law Enforcement.

We may disclose information if asked to do so by a law enforcement official: to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; or in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding PHI we maintain about you:

19.

Right to Inspect and Copy.

You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy PHI, you must submit your request in writing on the form provided by our Practice. We will usually respond to your request within sixty (60) days. If you request a copy of your PHI, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy your PHI in certain circumstances. If you are denied access to your PHI, you may request that the denial be reviewed in certain circumstances. Another licensed health care professional chosen by the Practice will review your request and our denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

20.

Right to Amend.

If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Practice. To request an amendment, your request must be made in writing on the form provided by our Practice. We will usually respond to your request within sixty (60) days. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: was not created by us; is not part of the PHI kept by or for the Practice; is not part of the information which you would be permitted to inspect and copy; or is already accurate and complete. If we deny your request for the amendment, we must let you know in writing. You have the right to disagree with our denial of your requested amendment and to have your disagreement placed in your medical record.

21.

Right to an Accounting of Disclosures.

You have the right to request that we provide you with an “accounting of disclosures.” This is a list of certain disclosures we made of your PHI that were not related to treatment, payment, health care operations, or any of the other routine uses or disclosures described in this Notice, were not required by law, and for which you did not sign an authorization. To request this list of disclosures, you just submit your request in writing on the form provided by the Practice. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003. We will provide the first list you request within any twelve (12) month period free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

22.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the PHI that we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI that we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. We can withdraw our agreement to a restriction by notifying you, in which case we are no longer restricted from releasing PHI about you that was created or received after we notify you. To request restrictions, you must make your request in writing on the form provided by our Practice.

23.

Right to Request Alternative Communications.

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential alternative communications, you must make your request in writing on the form provided by the Practice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

24.

Right to a Paper Copy of This Notice.

You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this notice, contact the office at the number listed on the first page.

OTHER USES OF PROTECTED HEALTH INFORMATION.

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose PHI about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by the written authorization. Please understand that we are not able to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we create or receive in the future. We will post our revised Notice in our waiting room [and on our website www.ohioeyeassociates.com]. If you would like a copy of the revised Notice, just ask us for one the next time you are in our office or call the office and we will mail a copy to you.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office and/or with the Secretary of the United States Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at the number listed on the first page of this Notice or submit your complaint in writing on the form provided by our Practice. You may also file a complaint with the Secretary of the United States Department of Health and Human Services at: Region V, Office for Civil Rights, U. S. Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, Illinois 60601; voice phone: 312-886-2359; facsimile: 312-886-1807; TDD: 312-353-5693. All complaints to the Secretary must be submitted in writing and no more than 180 days after the event that you are concerned about took place. You will not be penalized for filing a complaint.