|Effective:||June 6, 2007|
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT
INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
Vision Pro, P.A. (the “Practice”), in accordance with the federal Privacy Rule, 45 CFR
parts 160 and 164 (the “Privacy Rule”) and applicable state law, is committed to
maintaining the privacy of your protected health information (“PHI”). PHI includes
information about your health condition and the care and treatment you receive from
the Practice and is often referred to as your health care or medical record. This
Notice explains how your PHI may be used and disclosed to third parties. This Notice
also details your rights regarding your PHI.
HOW THE PRACTICE MAY USE AND
DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The Practice, in accordance with this Notice and without asking for your express
consent or authorization, may use and disclose your PHI for the purposes of:
(a) Treatment – To provide you with the health care you require, the Practice may
use and disclose your PHI to those health care professionals, whether on the Practice’
s staff or not, so that it may provide, coordinate, plan and manage your health care.
For example, a chiropractor treating you for lower back pain may need to know and
obtain the results of your latest physician examination or last treatment plan.
(b) Payment – To get paid for services provided to you, the Practice may provide
your PHI, directly or through a billing service, to a third party who may be responsible
for your care, including insurance companies and health plans. If necessary, the
Practice may use your PHI in other collection efforts with respect to all persons who
may be liable to the Practice for bills related to your care. For example, the Practice
may need to provide the Medicare program with information about health care
services that you received from the Practice so that the Practice can be reimbursed.
The Practice may also need to tell your insurance plan about treatment you are going
to receive so that it can determine whether or not it will cover the treatment expense.
(c) Health Care Operations – To operate in accordance with applicable law and
insurance requirements, and to provide quality and efficient care, the Practice may
need to compile, use and disclose your PHI. For example, the Practice may use your
PHI to evaluate the performance of the Practice’s personnel in providing care to you.
OTHER EXAMPLES OF HOW THE PRACTICE MAY USE YOUR PHI
(a) Advice of Appointment and Services – The Practice may, from time to time,
contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to
you. The following appointment reminders may be used by the Practice: a) a
postcard, letter, etc. mailed to you at the address provided by you; and b) telephoning
and leaving a message on your answering machine or with the individual answering
(b) Directory/Sign-In Log – The Practice may maintain a sign-in log at its reception
desk for individuals seeking care and treatment in the office. The sign-in log is
located in a position where staff can readily see who is seeking care in the office, as
well as the individual’s location within the Practice’s office suite. This information may
be seen by, and is accessible to, others who are seeking care or services in the
(c) Family/Friends – The Practice may disclose to a family member, other relative,
a close personal friend, or any other person identified by you, your PHI directly
relevant to such person’s involvement with your care or the payment for your care.
The Practice may also use or disclose your PHI to notify or assist in the notification
(including identifying or locating) a family member, a personal representative, or
another person responsible for your care, of your location, general condition or
death. However, in both cases, the following conditions will apply:
(i) If you are present at or prior to the use or disclosure of your PHI, the Practice
may use or disclose your PHI if you agree, or if the Practice can reasonably infer from
the circumstances, based on the exercise of its professional judgment, that you do not
object to the use or disclosure.
(ii) If you are not present, the Practice will, in the exercise of professional
judgment, determine whether the use or disclosure is in your best interests and, if so,
disclose PHI that is directly relevant to the person’s involvement with your care.
OTHER USE & DISCLOSURES WHICH MAY BE PERMITTED OR REQUIRED BY LAW
The Practice may also use and disclose your PHI without your consent or authorization
in the following instances:
(a) De-identified Information – The Practice may use and disclose health
information that may be related to your care but does not identify you and cannot be
used to identify you.
(b) Business Associate – The Practice may use and disclose PHI to one or more
of its business associates if the Practice obtains satisfactory written assurance, in
accordance with applicable law, that the business associate will appropriately
safeguard your PHI. A business associate is an entity that assists the Practice in
undertaking some essential function, such as a billing company that assists the office
in submitting claims for payment to insurance companies.
(c) Personal Representative – The Practice may use and disclose PHI to a person
who, under applicable law, has the authority to represent you in making decisions
related to your health care.
(d) Emergency Situations – The Practice may use and disclose PHI for the
purpose of obtaining or rendering emergency treatment to you provided that the
Practice attempts to obtain your Consent as soon as possible: The Practice may also
use and disclose PHI to a public or private entity authorized by law or by its charter to
assist in disaster relief efforts, for the purpose of coordinating your care with such
entities in an emergency situation.
(e) Public Health Activities – The Practice may use and disclose PHI when
required by law to provide information to a public health authority to prevent or control
(f) Abuse, Neglect or Domestic Violence – The Practice may use and disclose PHI
when authorized by law to provide information if it believes that the disclosure is
necessary to prevent serious harm.
(g) Health Oversight Activities – The Practice may use and disclose PHI when
required by law to provide information in criminal investigations, disciplinary actions, or
other activities relating to the community’s health care system.
(h) Judicial and Administrative Proceeding – The Practice may use and disclose
PHI in response to a court order or a lawfully issued subpoena.
(i) Law Enforcement Purposes – The Practice may use and disclose PHI, when
authorized, to a law enforcement official. For example, your PHI may be the subject of
a grand jury subpoena, or if the Practice believes that your death was the result of
(j) Coroner or Medical Examiner – The Practice may use and disclose PHI to a
coroner or medical examiner for the purpose of identifying you or determining your
cause of death.
(k) Organ, Eye or Tissue Donation – The Practice may use and disclose PHI if you
are an organ donor to the entity to whom you have agreed to donate your organs.
(l) Research – The Practice may use and disclose PHI subject to applicable legal
requirements if the Practice is involved in research activities.
(m) Avert a Threat to Health or Safety – The Practice may use and disclose PHI if
it believes that such disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the public and the disclosure is
to an individual who is reasonably able to prevent or lessen the threat.
(n) Specialized Government Functions – The Practice may use and disclose PHI
when authorized by law with regard to certain military and veteran activity.
(o) Workers’ Compensation – The Practice may use and disclose PHI if you are
involved in a Workers’ Compensation claim to an individual or entity that is part of the
Workers’ Compensation system.
(p) National Security and Intelligence Activities – The Practice may use and
disclose PHI to authorized governmental officials with necessary intelligence
information for national security activities.
(q) Military and Veterans – The Practice may use and disclose PHI if you are a
member of the armed forces, as required by the military command authorities.
Uses and/or disclosures, other than those described above, will be made only with
your written Authorization.
You have the right to:
(a) Revoke any Authorization or consent you have given to the Practice, at any
time. To request a revocation, you must submit a written request to the Practice’s
(b) Request special restrictions on certain uses and disclosures of your PHI as
authorized by law. In general, this relates to your right to request special restrictions
concerning disclosures of your PHI regarding uses for treatment, payment and
operational purposes under Privacy Rule, Section 164.522(a) and restrictions related
to disclosures to your family and other individuals involved in your care under Privacy
Rule, Section 164.510(b). Except in certain instances, the Practice may not be
obligated to agree to any requested restrictions. To request restrictions, you must
submit a written request to the Practice’s Privacy Officer. In your written request, you
must inform the Practice of what information you want to limit, whether you want to limit
the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If
the Practice agrees to your request, the Practice will comply with your request unless
the information is needed in order to provide you with emergency treatment.
(c) Receive confidential communications or PHI by alternative means or at
alternative locations as provided by Privacy Rule Section 164.522(b). For instance,
you may request all written communications to you marked “Confidential Protected
Health Information.” You must make your request in writing to the Practice’s Privacy
Officer. The Practice will accommodate all reasonable requests.
(d) Inspect and copy your PHI as provided by federal law (including Privacy Rule,
Section 164.524) and state law. To inspect and copy your PHI, you must submit a
written request to the Practice’s Privacy Officer. The Practice can charge you a fee
for the cost of copying, mailing or other supplies associated with your request. In
certain situations that are defined by law, the Practice may deny your request, but you
will have the right to have the denial reviewed as set forth more fully in the written
(e) Amend your PHI as provided by federal law (including Privacy Rule, Section
164.526) and state law. To request an amendment, you must submit a written request
to the Practice’s Privacy Officer. You must provide a reason that supports your
request. The Practice may deny your request if it is not in writing, if you do not
provide a reason in support of your request, if the information to be amended was not
created by the Practice (unless the individual or entity that created the information is
no longer available), if the information is not part of your PHI maintained by the
Practice, if the information is not part of the information you would be permitted to
inspect and copy, and/or if the information is accurate and complete. If you disagree
with the Practice’s denial, you will have the right to submit a written statement of
(f) Receive an accounting of disclosures of your PHI as provided by federal law
(including Privacy Rule Section 164.528) and state law. To request an accounting,
you must submit a written request to the Practice’s Privacy Officer. The request must
state a time period, which may not be longer than six (6) years and may not include
dates before April 14, 2003. The request should indicate in what form you want the
list (such as a paper or electronic copy). The first list you request within a twelve (12)
month period will be free, but the Practice may charge you for the cost of providing
additional lists. The Practice will notify you of the costs involved and you can decide
to withdraw or modify your request before any costs are incurred.
(g) Receive a paper copy of this Privacy Notice from the Practice (as provided by
Privacy Rule Section 164.520(b)(1)(iv)(F)) upon request to the Practice’s Privacy
(h) Complain to the Practice or to the Secretary of HHS (as provided by Privacy
Rule Section 164.520(b)(1)(vi)) if you believe your privacy rights have been violated.
To file a complaint with the Practice, you must contact the Practice’s Privacy Officer.
All complaints must be in writing.
To obtain more information about your privacy rights or if you have questions you
want answered about your privacy rights (as provided by Privacy Rule Section 164.520
(b)(2)(vii)), you may contact the Practice’s Privacy Officer as follows:
Paul Proske, O.D.
Vision Pro, P.A.
20920 Kuykendahl Rd., Suite C
Spring, TX 77388
(a) Is required by federal law to maintain the privacy of your PHI and to provide
you with this Privacy Notice detailing the Practice’s legal duties and privacy practices
with respect to your PHI.
(b) Under the Privacy Rule, may be required by State law to grant greater access
or maintain greater restrictions on the use or release of your PHI than that which is
provided for under federal law.
(c) Is required to abide by the terms of this Privacy Notice.
(d) Reserves the right to change the terms of this Privacy Notice and to make the
new Privacy Notice provisions effective for all of your PHI that it maintains.
(e) Will not retaliate against you for filing a complaint.
EFFECTIVE DATE: THIS NOTICE IS IN EFFECT AS OF 06/06/07.
|Privacy Contact Officer:||Paul Proske, O.D.|