Insurance

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.

DURING YOUR NEXT ENCOUNTER MODERN OPTICAL YOU WILL BE ASKED TO SIGN A FORM ACKNOWLEDGING RECEIPT OF EYE CARE SPECIALISTS' NOTICE OF PRIVACY PRACTICES. THE DELIVERY OF YOUR HEALTH CARE SERVICES WILL IN NO WAY BE CONDITIONED UPON YOUR SIGNED ACKNOWLEDGEMENT. IF YOU DECLINE TO PROVIDE A SIGNED ASKNOWLEGEMENT, WE WILL CONTINUE TO PROVIDE YOUR TREATMENT, AND WILL USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS WHEN NECESSARY.

The Doctors and employees of Modern Optical respect your privacy. We understand that your personal health information is very sensitive and private. The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnosis, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Questions and Answers

What is the Notice of Privacy Practices? The Notice of Privacy Practices informs you about how your personal and health information at Modern Optical may be used and disclosed, and your rights regarding that information.

What am I being asked to sign? You are being asked to confirm for us that you have received this Notice by signing your name on the acknowledgement form provided and returning it to us.

Who is supposed to sign the acknowledgement? You and any other family member that Modern Optical specialists provide services to need to sign the acknowledgement. Parents should sign for children younger than 18 years of age.

Modern Optical responsibilities to our patients

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Modern Optical specialists must take steps to protect the privacy of your "protected health information" (PHI). PHI includes information that we have created or received regarding your health or payment for services rendered for your health care. It includes both your medical records and personal information such as your name, date of birth, social security number, addresses and phone numbers.

Under federal law, we are required to:

• Protect the privacy of your PHI. Our Doctors and employees are required to maintain the confidentiality of PHI and receive appropriate privacy training.
• Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI.
• Follow the practices and procedures set forth in the Notice.

Changes to Privacy Practices

Modern Optical may change the terms of this Notice at any time. The revised Notice would apply to all PHI that we maintain. If we change any of the practices described in this Notice, we will post the revised Notice on the Modern Optical web site and at our facility. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up.

Your Health Information Rights

The health and billing records we create and store are the property of Eye Care Specialists. The protected health information in it, however, generally belongs to you. You have a right to:

• Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. Please note, we are not required to grant the request, but we will honor your restrictions unless it is an emergency situation.
• Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected Health Information.
• Request that you be allowed to see and get a copy of your protected health information. We may ask you to make this request in writing and we may charge a reasonable fee for the cost of producing and mailing the copies. In certain situations we may deny your request and will tell you why we are denying it. In some cases you may have a right to ask for a review of our denial. We have a form available for this type of request.
• Give us a written request to change your health information. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and be included with any release of your records.
• Request an accounting of disclosures of your PHI. The list will not include disclosures to third party payers. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
• Request that your health information be given to you by another means or at another location. For example, if you want us to communicate with you at a different address we can usually accommodate that request. We may ask that you make your request to us in writing. We will agree to reasonable requests.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have received the revocation. Sometimes you cannot cancel an authorization if its purpose was to obtain insurance.

Uses and disclosures of your protected health information by Modern Optical that do NOT require your authorization.

Eye Care Specialists uses and discloses PHI in a number of ways connected to your treatment, payment for your care, and our healthcare operations. Some examples of how we may use or disclose your PHI without your authorization are listed below.

In relation to your health care and treatment:

• To our Doctors, opticians, technicians involved in your eye health care.
• To our different departments to coordinate such activities as testing, prescriptions, glasses.
• To other health care providers treating you who are not on our staff such as your primary care physician, emergency room staff, and specialists. For example, if you are being treated for an injured eye we may share your PHI among your primary care physician, and the retinal specialist so they can provide proper care.

In relation to payment:

• To administer your health benefits policy or contract.
• To bill you for health care we provide.
• To pay others who provide care to you.
• To other organizations and providers for payment activities unless disclosure is prohibited by law.

In relation to health care operations:

• To assess quality and improve services
• To review performance and training of staff
• To remind you about appointments, give you information about treatment alternatives or other health-related benefits and services.
• To conduct or arrange for services, including:
  • Medical quality review by your health plan
  • Accounting, legal, risk management and insurance services
  • Audit functions, including fraud and abuse detection and compliance programs.

(Note: if we share your PHI with organizations that provide the above mentioned services, they must agree to protect your privacy.)

Modern Optical may use or disclose your PHI without your authorization for legal and/or governmental purposes in the following circumstances:

• As required by law - when we are required to do so by state and/or federal law, including worker's compensation laws.
• Public health and safety. To an authorized public health authority or individual
  • to protect public health and safety,
  • to prevent or control disease, injury or disability,
  • to report vital statistics such as births or deaths,
  • to investigate or track problems with prescription drugs, food, supplements and medical devices by the Food and Drug Administration.
• Abuse or neglect. To government entities authorized to receive reports regarding abuse, neglect or domestic violence.
• Oversight agencies. To health oversight agencies for certain activities such as audits, examinations, investigations, inspections and licensures.
• Legal proceedings. In the course of any legal proceeding in response to an order of a court or administrative agency and, in certain cases, in response to a subpoena, discovery, request or other lawful process.
• Law enforcement. To law enforcement officials in limited circumstances for law enforcement purposes. For example disclosures may be made to identify or locate a suspect, witness, or missing person; to report a crime; or to provide information concerning victims of crimes.
• Military activity and national security. To the military and to authorized federal officials for national security and intelligence purposes or in connection with providing protective services to the president of the United States.

Modern Optical may also use or disclose your PHI without your authorization in the following miscellaneous circumstances:

• To family and friends who are directly involved in your health care and you are either not present or unable to make a health care decision for yourself and we determine that disclosure is in your best interest. For example, we may disclose post-operative condition and care instructions to family member or friend of patient with whom the patient will be recovering.
• To medical researchers if the research has been approved and has policies in place to protect the privacy of your PHI.
• To coroners, funeral directors and organ procurement organizations as authorized by law.
• To correctional facilities. If you are an inmate in a correctional facility we may disclose your PHI to the correctional facility for certain purposes, such as providing health care to you or protecting your health and safety or that of others.
• For disaster relief purposes. For example we may share PHI with disaster relief agencies to assist in notification of your condition to family or others.