Please make sure that you take time to read and look over Eye2Eye Vision Privacy Notice:
Thomas Rene, O.D.
1695 43rd Street South
Fargo, ND 58103
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information may be used and disclosed, and how you can access this information. Please review this policy carefully. If you have any questions about this notice, please contact the Facility Privacy Officer at 701-235-3937.
Each time you visit Eye2Eye Vision a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment, and billing related information. This notice applies to all the records of your care generated by our facility personnel or agents of the facility.
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
Uses and Disclosures
How we may use and disclose medical information about you.
The following categories describe examples of the way we use and disclose medical information:
For treatment: We may use medical information about you to provide you treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital/long term care personnel who are involved in your care. For example: a doctor treating your diabetes would be appropriate to discuss your condition with if you are scheduled for surgery because diabetes may slow the healing process. Designated staff of Eye2Eye Vision also may share medical information about you in order to coordinate the different things you may need, such as surgical procedures, prescriptions, x-rays, audiology services or lab work. We may also provide a referring healthcare provider with copies of various reports that should assist him or her in treating you or coordinating your care with Eye2Eye Vision.
For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.
For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients/residents we serve. For example, we may combine medical information about many patients/residents to evaluate the need for new services, treatment, or equipment. We many disclose information to doctors, nurses, and other students for educational purposes.
We may also use and disclose medical information:
- To business associates we have contracted with to perform the agreed upon service and bill for it;
- To remind you that you have an appointment for medical care;
- To assess your satisfaction with our services;
- To tell you about possible treatment alternatives;
- To tell you about health-related benefits or services;
- For Population based activities relating to improving health or reducing health care costs;
- For conducting training programs and reviewing competence of health care professionals.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples may include an outside billing service, audiology services, or certain outside laboratories. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third party for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Directory: We may acknowledge if you are present in our facility if asked by another person unless you have instructed us otherwise. For example, your spouse may come into the clinic and inquire if you are present.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.
Future Communications: We may communicate to you via newsletters, mail outs, or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our facility is participating in.
Affiliated Covered Entity: Protected health information will be made available to your family or referring physician as necessary to carry out treatment, payment, and health care operations.
As Required by Law:
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health, and the health and safety of other individuals.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.
Federal Law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.
Individual Health Information Rights
Although your health record is the physical property of the clinic that compiled it, you have the Right to:
- Inspect and Copy:You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Amend:If you feel that medical information 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 our facility. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
- An Accounting of Disclosures:You have the right to request an accounting of disclosures. This is a list of the disclosures we make of medical information about you.
- Request Restrictions:You have the right to request a restriction or limitations on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
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 emergency treatment.
- Request Confidential Communications:You have the right to request that we communicate about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.
- 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 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 exercise any of your rights, please obtain the required forms from a designated staff member for Eye2Eye Vision and submit your request in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the clinic and include the effective date. In addition, each time you register at Eye2Eye Vision for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the clinic by contacting the main number and asking for the Facility Privacy Officer or with the Complaint Division Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.
Thomas Rene, O.D.
(Telephone Number: 701-235-3937)