THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Note: If you have questions about this notice,
please contact the Privacy Officer at Mauer Eye Center, P.C., 3410 Kimball
Avenue, Waterloo, IA 50702.
WHO WILL FOLLOW THIS NOTICE:
This
notice describes the privacy practices of Mauer Eye Center, P.C.
All of our physicians
and staff may have access to information in your chart for treatment, payment
and health care operations, which are described below, and may use and disclose
information as described in this Notice.
This Notice also applies to any volunteer or trainee we allow to help
you while seeking services from us.
OUR PLEDGE REGARDING THE PRIVACY OF YOUR MEDICAL INFORMATION:
Your
medical information includes information about your physical and mental
health. We understand that information
about your physical and mental health is personal. We are committed to protecting medical information about
you. We create a record of the care and
services you receive from us. We need this record to provide you with quality
care and to comply with certain legal requirements. This notice applies to any and all of the records of your care
generated by us.
This
notice will tell you about the ways in which we may use and disclose medical
information about you. We also describe
your rights and certain obligations we have regarding the use and disclosure of
medical information.
We
reserve the right to revise or amend our notice of privacy practices without
additional notice to you. Any revision
or amendment to this notice will be effective for all of your records our
practice has created or maintained in the past, and for any of your records we
may create or maintain in the future. We will post a copy of our current notice
in our offices in a prominent place and will post the notice on our website.
OUR OBLIGATIONS TO
YOU
We are required by
law to:
·
make sure that
medical information that identifies you is kept private except as otherwise
provided by state or federal law;
·
give you this notice
of our legal duties and privacy practices with respect to medical information
about you; and
·
follow the terms of
the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The
following categories describe different ways that we may use and disclose
medical information. For each category
of uses or disclosures we will explain what we mean and try to give some
examples. Not every use or disclosure
in a category will be listed. This
notice covers treatment, payment, and what are called health care operations,
as discussed below. It also covers
other uses and disclosures for which a consent or authorization are not
necessary. Where Iowa law is more
protective of your medical information, we will follow state law, as explained
below.
For
Treatment. We may use medical information about you to
provide you with medical treatment or services without consent or authorization
unless otherwise required by applicable state law. We may disclose medical information about you to doctors, nurses,
medical students, pharmacists, laboratories, or other health care providers who
are involved in taking care of you whether or not they are affiliated with
us. For example, we may disclose
medical information concerning you to hospitals or physicians who refer your
care to us as well as to any other entity that has provided or will provide
care to you. We will disclose any
mental health information, including psychotherapy notes, AIDS or HIV-related
information, or drug treatment information, that we may have about you only
with written authorization as required by Iowa law, HIPAA and other federal
regulations.
During
the course of your treatment, we may refer you to other health care providers
such as independent laboratories with which you may not have direct patient
contact. These providers are called
"indirect treatment providers."
"Indirect treatment providers" are required to comply with the
privacy requirements of state and federal law and keep your medical information
confidential. These providers will be
bound by the HIPAA privacy rule.
For
Payment. We may use and disclose medical information
about you without consent or authorization so that the treatment and services
you receive from us may be billed to and payment may be collected from you, an
insurance company or a third party. For
example, we may need to give your health plan information about treatment
received so your health plan will pay us or reimburse you for the
treatment. We may also tell your health
plan or insurance company about a treatment you are going to receive to obtain
prior approval or to determine whether it will cover the treatment.
For
Health Care Operations. We may use and disclose medical information
about you without consent or authorization for "health care
operations". These uses and
disclosures are necessary to operate our practice and make sure that all of our
patients receive quality care. For
example, we may use medical information or mental health treatment information
to review our treatment and services and to evaluate the performance of our
staff in caring for you. We may also
disclose your protected health information to doctors, nurses, medical students
and other employees or consultants for review and learning purposes. We may also use your protected health
information in preparing for litigation.
Appointment
Reminders. We may use and disclose medical information
to contact you by mail or phone to remind you that you have an appointment for
treatment, unless you tell us otherwise in writing.
Treatment
Alternatives. We may use and disclose medical information
to tell you about or recommend possible treatment options or alternatives that
may be of interest to you. However, we will not use or disclose medical
information to market other products and services, either ours or those of
third parties, without your authorization.
Health-Related
Benefits and Services. We may use and disclose medical information
to tell you about health-related benefits or services that may be of interest
to you.
Individuals
Involved in Your Care or Payment for Your Care. We may release medical
information about you to a family member who is involved in your medical care
without consent or authorization. We
may also give medical information, including prescription information or
information concerning your appointments to friends who are involved in your
care. We may also give such
information to someone 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.
As
Required By Law. We will disclose medical information about
you when required to do so by federal, state or local law without your consent
or authorization.
To
Avert a Serious Threat to Health or Safety. We may disclose medical information about
you when necessary to prevent a serious threat to your health and safety or the
health and safety of the public or another person. Any disclosure, however, would only be to someone able to help
prevent the threat.
To
Business Associates. Mauer Eye Center, P.C.
from time to time will hire consultants called "business associates,"
who render services to us. We may
disclose your medical information to such business associates without your
consent or authorization. Business associates
are required to maintain and comply with the privacy requirements of state and
federal law and keep your medical information confidential. Examples of "business associates" are accounting firms that we hire
to perform audits of billing and payment information, and computer software
vendors who assist us in maintaining and processing medical information.
Military
and Veterans. If you are a member of the armed forces, we
may release medical information about you as required by military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military authority.
Worker’s
Compensation. We may release medical information about you
for workers’ compensation or similar programs without consent or
authorization. These programs provide
benefits for work-related injuries or illnesses. For example, if you are injured on the job, we may release
information regarding that specific injury.
Public Health Risks. We may disclose
medical information about you for public health activities without your consent
or authorization. These activities
generally include the following:
·
to prevent or control
disease, injury or disability;
·
to report reactions
to medications or problems with products;
·
to notify people of
recalls of products they may be using;
·
to notify a person
who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition;
·
to notify the
appropriate government authority if we believe a patient has been the victim of
abuse, neglect or domestic violence. We
will only make this disclosure if you agree or when required or authorized by
law.
Health
Oversight Activities. We may disclose medical information to a
health oversight agency, such as the Department of Health and Human Services,
for activities authorized by law. These
oversight activities include, for example, audits, investigations, inspections,
and licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Lawsuits
and Administrative Proceedings. If you are involved in a lawsuit or dispute
as a party, we may disclose medical information about you in response to a
court or administrative order. We may
also disclose medical information about you in response to a subpoena,
discovery request, or other lawful process by someone else involved in the
dispute. Similarly we may disclose
medical information about you in proceedings where you are not a party, but
only if efforts have been made to tell you or your attorney about the request
or to obtain an order protecting the information requested. In addition, we may disclose medical
information, including mental health treatment information, to the opposing
party in any lawsuit or administrative proceeding where you have put your
physical or mental condition at issue if you have signed a valid authorization.
Law
Enforcement. We may release medical information if asked
to do so by a law enforcement official:
·
in response to a
court order, subpoena, warrant, summons or similar process;
·
to identify or locate
a suspect, fugitive, material witness, or missing person;
·
about the victim of a
crime if, under certain limited circumstances, we are unable to obtain the
person’s agreement;
·
about a death we
believe may be the result of criminal conduct;
·
about criminal
conduct at Abbe Inc.Medical Associates
Clinic; and
·
in emergency
circumstances to report a crime; the location of the crime or victims; or the
identity, description or location of
the person who committed the crime.
Coroners,
Medical Examiners and Funeral Directors. We may release medical information including
mental health information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death.
National
Security and Intelligence Activities. We may release medical information about you
to authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective
Services for the President and Others. We may disclose medical information about
you to authorized federal officials so they may provide protection to the
President, other authorized persons or foreign heads of state or conduct
special investigations.
Inmates. If you are an
inmate of a correctional institution or under the custody of a law enforcement
official, we may release medical information about you to the correctional
institution or law enforcement official.
This release would be necessary (1) for the institution to provide you
with health care; (2) to protect your health and safety or the health and
safety of others; or (3) for the safety and security of the correctional
institution.
YOUR RIGHTS REGARDING MEDICAL
INFORMATION ABOUT YOU.
You
have the following rights regarding medical information we maintain about you:
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.
If
you wish to be provided a copy of medical information that may be used to make
decisions about you, you must submit your request in writing to Privacy
Officer, Mauer Eye
Center, P.C. If you request a copy of the information, we
may charge a reasonable fee for the costs of copying, mailing and or other
supplies associated with your request.
We
may deny your request to inspect and/or obtain a copy in certain very limited
circumstances. If you are denied access
to medical information, you may request that the denial be reviewed. Another licensed health care professional
chosen by us will review your request and the denial. The person conducting the review will not be the person who
denied your request. We will comply
with the outcome of the review.
Right
to Request an Amendment. 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 or for us.
To
request an amendment, your request must be made in writing and submitted to
Privacy Officer, Mauer
Eye Center, P.C., Mauer Eye Center, 3410 Kimball Avenue, Waterloo, IA
50702. In
addition, you must provide a reason that supports your request.
We
may deny your request for an amendment if it is not in writing or does not
include a reason to support the request.
In addition, we may deny your request if you ask us to amend information
that:
·
Was not created by
us, unless the person or entity that created the information is no longer
available to make that amendment;
·
Is not part of the
medical information kept by us
·
Is not part of the
information which you would be permitted to inspect and copy; or
·
Is accurate and
complete.
Right
to an Accounting of Disclosures. You have the right to request an “accounting
of disclosures.” This is a list of the
disclosures we made of medical information about you.
To
request this list or accounting of disclosures, you must submit your request in
writing to Privacy Officer, Mauer Eye Center, P.C., _______________________. Your request must
state a time period which may not be longer than six years starting with April
15, 2003. Your request will be provided
to you on paper. The first list you
request within a 12-month period will be free.
For additional lists, we may charge you for the costs of providing the
list. We will notify you of the cost
involved and you may choose to withdraw or modify your request at that time
before any costs are incurred.
Right
to Request Restrictions. You have the right to request a restriction
or limitation 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 the payment for
your care, like a family member or friend.
For example, you may request that your spouse or child who is involved
in your care not receive certain information about your condition.
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.
To
request restrictions, you must make your request in writing to Mauer Eye Center, P.C.'s Privacy
Officer. In
your request, you must tell us (1) what information you want to limit; (2)
whether you want to limit our use, disclosure or both; and (3) to whom you want
the limits to apply, for example, disclosures to your spouse.
Right
to Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain
location. For example, you can ask that
we only contact you at work or by mail.
To
request confidential communications, you must make your request in writing to Mauer Eye Center, P.C.'s Privacy
Officer. We will not ask the reason for your
request. We will accommodate all
reasonable requests. Your request must
specify how or where you wish to be contacted.
Right
to 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.
You
may obtain a copy of this notice at our web site [__________________________].
COMPLAINTS. If you believe your
privacy rights have been violated, you may file a complaint with us or with the
Secretary of the Department of Health and Human Services. To file a complaint with us, submit your
complaint in writing to Privacy Officer, Mauer Eye Center, P.C., 3410 Kimball Avenue, Waterloo,
IA 50702. 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 as set out in an authorization signed by
you. 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 to you.
[USE YOUR LOGO--THE ACKNOWLEDGMENT CAN AND
SHOULD BE A SEPARATE DOCUMENT FROM NOTICE]
ACKNOWLEDGMENT
I acknowledge that on ___ day of ,200 ,
I received a copy of Mauer Eye Center, P.C.’s Notice of Privacy Practices.
Dated this _____ day
of
, 200__.
or
Legal Guardian or Personal Representative
[or other relationship]