BELLINGHAM FAMILY EYE CLINIC450-B BIRCHWOOD AVE.BELLINGHAM, WA 98225(360) 738-7700
EFFECTIVE DATE OF NOTICE: AUGUST 31, 2013NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSEYOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READIT CAREFULLY. Your "health information," for purposes of this Notice, is generally any information that identifies you and iscreated, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as"health information" in this Notice).
We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicablelaws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacypractices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affectedindividuals following a breach of their unsecured health information.
USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION
The most common reasons why we use or disclose your health information are for treatment, payment or health careoperations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment foryou; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showingyou low vision aids; referring you to another doctor or clinic for care or low vision aids or services; or getting copies of yourhealth information from another professional that you may have seen before us. Examples of how we use or disclose your healthinformation for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparingand sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Healthcare operations" mean those administrative and managerial functions that we must carry out in order to run our office. Examplesof how we use or disclose your health information for health care operations are: financial or billing audits; internal qualityassurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outsidestorage of our records.
OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT
In some limited situations, the law allows or requires us to use or disclose your health information without your consentor authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosuresare:• when a state or federal law mandates that certain health information be reported for a specific purpose;• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and fromthe federal Food and Drug Administration regarding drugs or medical devices;• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare orMedicaid; or for investigation of possible violations of health care laws;• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts oradministrative agencies;• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be avictim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhereelse;• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors toaid in burial; or to organizations that handle organ or tissue donations;• uses or disclosures for health related research;• uses and disclosures to prevent a serious threat to health or safety;• uses or disclosures for specialized government functions, such as for the protection of the president or high rankinggovernment officials; for lawful national intelligence activities; for military purposes; or for the evaluation and healthof members of the foreign service;• disclosures of de-identified information;• disclosures relating to worker’s compensation programs;• disclosures of a "limited data set" for research, public health, or health care operations;• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;• disclosures to "business associates" and their subcontractors who perform health care operations for us and whocommit to respect the privacy of your health information in accordance with HIPAA;Unless you object, we will also share relevant information about your care with any of your personal representatives who arehelping you with your eye care. Upon your death, we may disclose to your family members or to other persons who wereinvolved in your care or payment for heath care prior to your death (such as your personal representative) health informationrelevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to yourdeath.
SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosures we may not make of your health information without yourauthorization:
Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information formarketing purposes unless such marketing communications take the form of face-to-face communications we may make withindividuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from athird party your authorization must also include consent to such payment.
Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorizationprior to doing so.
Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify youthat we generally must obtain your authorization prior to using or disclosing any such notes.
YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES
• Other uses and disclosures of your health information that are not described in this Notice will be made only with yourwritten authorization.
• You may give us written authorization permitting us to use your health information or to disclose it to anyone for anypurpose.
• We will obtain your written authorization for uses and disclosures of your health information that are not identified inthis Notice or are not otherwise permitted by applicable law.
• We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is forthe purpose of carrying out payment or health care operations and is not otherwise required by law and suchinformation pertains solely to a health care item or service for which you have paid in full (or for which another personother than the health plan has paid in full on your behalf).
Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you inwriting at any time. After you revoke your authorization, we will no longer use or disclose your health information for thereasons described in the authorization. However, we are generally unable to retract any disclosures that we may have alreadymade with your authorization. We may also be required to disclose health information as necessary for purposes of payment forservices received by you prior to the date you revoked your authorization.
YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
• To request restrictions on the health information we may use and disclose for treatment, payment andhealth care operations. We are not required to agree to these requests. To request restrictions, please send a writtenrequest to us at the address below.
• To receive confidential communications of health information about you in any manner other thandescribed in our authorization request form. You must make such requests in writing to the address below.However, we reserve the right to determine if we will be able to continue your treatment under such restrictiveauthorizations.
• To inspect or copy your health information. You must make such requests in writing to the address below.If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or othersupplies. In certain circumstances we may deny your request to inspect or copy your health information, subject toapplicable law.
• To amend health information. If you feel that health information we have about you is incorrect orincomplete, you may ask us to amend the information. To request an amendment, you must write to us at the addressbelow. You must also give us a reason to support your request. We may deny your request to amend your healthinformation if it is not in writing or does not provide a reason to support your request. We may also deny your requestif the health information:
o was not created by us, unless the person that created the information is no longer available to make theamendment,
o is not part of the health information kept by or for us,
o is not part of the information you would be permitted to inspect or copy, or
o is accurate and complete.
• To receive an accounting of disclosures of your health information. You must make such requests inwriting to the address below. Not all health information is subject to this request. Your request must state a time periodfor the information you would like to receive, no longer than 6 years prior to the date of your request and may notinclude dates before April 14, 2003. Your request must state how you would like to receive the report (paper,electronically).
• To designate another party to receive your health information. If your request for access of your healthinformation directs us to transmit a copy of the health information directly to another person the request must be madeby you in writing to the address below and must clearly identify the designated recipient and where to send the copy ofthe health information.
Our contact person for all questions, requests or for further information related to the privacy of your health information is:_Julie St.Pierre, CPOA_____________________Paula J. Green, CPO____________________
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to theU.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make acomplaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mailshown above. If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that wealready have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in ourfacility. Copies of this Notice are also available upon request at our reception area.Notice Revised and Effective: August 31, 2013
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Bellingham Family Eye Clinic, Notice of Privacy Practices, dated August 31, 2013. Imay request a copy if I desire one for my own records.