| Privacy Notice
Advanced Perspectives Eye Care
HIPAA Notice of Privacy Practices for Personal Health Information Effective
Date: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
Dear Customer of Advanced Perspectives Eye Care:
We are required to provide you with this Notice of Privacy Practices and
to explain our legal duties under the Federal Health Insurance Portability
and Accountability Act (HIPAA). By law, we are required to:
• maintain the privacy of your Personal Health Information (PHI);
• provide you this notice of our legal duties and privacy practices
with respect to your PHI; and
• follow the terms of this notice.
How We Collect Information:
We obtain most PHI directly from the Individual. The Information that
an Individual gives us when registering for a services generally provides
the Information we need. An individual’s clinical information is
forwarded directly to the individual and some form of record is either
retained in secure hard copy file. If we need to verify information or
need additional information, we may obtain information from third parties
such as adult family members or employers. Information collected may relate
to an individual’s demographics, employment, health, avocations
or other personal characteristics which may assist us in evaluating the
individual’s healthcare. In most cases we do not retain the dates
and locations where service was provided.
We protect your PHI from inappropriate use or disclosure. Our employees,
and those of companies that help us service your health care, are required
to comply with our requirements that protect the confidentiality of your
PHI. They may look at your PHI only when there is appropriate reason to
do so, such as to administer the process of returning your health test
results back to you.
We will not knowingly disclose or sell your PHI to any other individual
or organization for their use in marketing products to your without your
prior consent.
We will not forward by mail, fax or electronically your PHI to any healthcare
provider without your prior written consent.
We will not make available your PHI to your employer or any 3rd party
carrier without your prior written consent.
We May Use and Disclose PHI about You without Your Authorization unless
you object as described below, together with some examples:
• Appointments and Other Health Information: We may send you reminders
for medical care or checkups. We may send you information about future
health services that may be of interest to you as a health conscious individual.
For example, we will send mailings to you as a prior customer
• Research: We may use PHI about you for studies and to develop
reports. These reports do not identify specific people. For example, we
may want to determine how many individuals of an age range wear multifocal
lenses.
• Future Business: PHI may be disclosed as part of a potential merger
or acquisition involving our business in order to make an informed decision
regarding any such prospective transaction. Should a merger or acquisition
take place, our database of names and addresses may be part of the process.
• Where Required by Law or for Public Health Activities: We may
disclose PHI when required by federal, state or local law. Examples of
such mandatory disclosures include notifying state or local health authorities
regarding particular communicable diseases, or providing PHI to a government
agency or regulator with health care oversight responsibilities. We may
also release PHI to a coroner or medical examiner to assist in identifying
a diseased individual or to determine the cause of death.
• For Payment: We may use or disclose PHI about you to get payment
or to pay for health care services you receive. For example, we may provide
PHI to bill your health plan for health care provided to you.
• To Avert a Serious Threat to Health or Safety: We may disclose
PHI about you to law enforcement in order to avoid a serious threat to
the health and safety of a person or the public.
• For Law Enforcement or Specific Government Functions: We may disclose
PHI in response to a request by law enforcement official made through
a court order, subpoena, warrant, summons or similar process. We may disclose
PHI about you to federal officials for intelligence, counterintelligence,
and other national security activities authorized by law.
• When Requested as Part of a Regulatory or Legal Proceeding: If
you or your estate is involved in a lawsuit or a dispute, we may disclose
PHI about you in response to a court or administrative order. We may also
disclose PHI about you in response to a subpoena, discovery request, or
other lawful process by someone else involved in the dispute, but only
if efforts have been made to tell you about the request or to obtain an
order protecting the PHI requested. We may also disclose PHI to any governmental
agency or regulator with whom you have filed a complaint or as part of
a regulatory agency examination.
• Other Uses of PHI: Other uses and disclosures of PHI not covered
by this notice and permitted by the laws that apply to us will be made
only with your written authorization or that of your legal representative.
If we are authorized to use or disclose PHI about you, you or your legally
authorized representative may revoke that authorization, in writing, at
any time. We cannot take back any uses or disclosures already made with
your authorization.
• Disclosure to Family, Friends, and Others: We may disclose PHI
about you to your family or other persons who are involved in your medical
care.
• Directory: We may use PHI about you to assist visitors at our
facilities to locate you or to inform clergy about you.
Your PHI Privacy Rights
• Right to See and Get Copies of Your PHI. In most cases, you have
the right to look at or get copies of your PHI. You must make the request
in writing and include dates and location(s) of service. You may be charged
a fee for the cost of copying and mailing the PHI to you.
• Right to Request to Correct or Update Your PHI. You may ask us
to change or add missing PHI if you think there is a mistake. You must
make the request in writing and provide a reason for your request. However,
there are conditions under which we may deny this request.
• Right to Get a List of Disclosures. You have the right to ask
us for a list of disclosures made after April 14, 2003 and up to six years
prior to the date you made the request. You must make the request in writing.
• Right to Request Limits on Uses or Disclosures of Your PHI. You
have the right to ask us to limit how PHI about you is used or disclosed.
You must make the request in writing and tell us what PHI you want to
limit and to whom you want the limits to apply. In your request, you must
you must tell us (1) dates and location(s) of service (2) what information
you want to limit; (3) whether you want to limit our use, disclosure ,
or both; and (4) to whom you want the limits to apply (for example , disclosure
to your spouse or parent). To make a request, you must make your request
in writing to Privacy Coordinator, Advanced Perspectives Eye Care, 4901
N 44th St, Suite 102, Phoenix, AZ 85018. We will not agree to restrictions
on PHI uses or disclosures that are legally required, or which are necessary
to administer our business. While we will consider your request, we are
not required to agree to it. If we do agree to it, we will comply with
your request.
• Right to Revoke Permission. If you are asked to sign an authorization
to use or disclose PHI about you, you can cancel that authorization at
any time. You must make the request in writing. This will not affect PHI
that has already been shared.
• Right To Choose How We Communicate With You. You have the right
to ask us to share your PHI with you in a certain way or in a certain
place. For example, you may ask us to send PHI about you to your work
address instead of your home address. You must make this request in writing.
You do not have to explain the basis for your request.
• Right to File a Complaint. You have the right to file a complaint
if you do not agree with how we have used or disclosed PHI about you.
All complaints must be submitted in writing. Your services will not be
affected by any complaints you make. We cannot retaliate against you for
filing a complaint or refusing to agree to something that you believe
to be unlawful.
• Right to Get a Paper Copy of this Notice. You have the right to
ask for a paper copy of this notice at any time.
ADDITIONAL INFORMATION
We reserve the right to change the terms of this Notice of Privacy Practices
at any time. Any changes will apply to information we already have and
any information we receive in the future. A copy of the new notice will
be provided to individuals upon request as required by law. You may request
a copy of the current notice at anytime.
HOW TO FILE A COMPLAINT OR REPORT A PROBLEM
Advanced Perspectives Eye Care
4901 N 44th Street, Suite 102
Phoenix, AZ 85018
Ph: (602) 955-2700
Fax: (602) 955-3282
Contact person: HIPAA Compliance Officer
You may contact the person listed above if you want to file a complaint
or to report a problem with how we have used or disclosed your PHI. Your
services will not be affected by any complaints you make. We cannot retaliate
against you for filing a complaint, cooperating in an investigation, or
refusing to agree to something that you believe to be unlawful. You may
also file a complaint with the US Department of Health and Human Services,
Office of Civil Rights by contacting:
Office for Civil Rights U.S. Department of Health & Human Services
50 United Nations Plaza - Room 322
San Francisco, CA 94102
(415) 437-8310; (415) 437-8311 (TDD) (415) 437-8329 FAX
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