Round Valley Vision Center
Privacy Notice

NOTICE OF PRIVACY PRACTICES

Effective date of notice: 3/20/2003
Round Valley Vision Center/Dr. Steven P. Heap
39 E. 1st Street,
Eagar, Arizona 85925
Phone: (928)333-4396 Fax: (928)333-5050

 

General Rule

We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices.

Generally, we can only use your health information in our office or disclose it outside of our office, without you written permission, for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.

Uses or Disclosures of Health Information

Examples of how we use information for TREATMENT purposes:
* When we set up an appointment for you.
* When our technician or doctor tests
your eyes.
* When the doctor prescribes glasses or
contact lenses.
* When the doctor prescribes medication.
* When our staff helps you select and
order glasses or contact lenses.
* When we show you low vision aids.

We may disclose your healthe information outside of our office for TREATMENT purposes, for example:
* If we refer you to another doctor or
clinic for eye care or low vision aids
or services.
* If we send a prescription for glasses
or contacts to another professional to
be filled.
* When we provide a prescription for
medication to a pharmacist.
* When we phone to let you know that your
glasses or contact lenses are ready to
be picked up.

Sometimes we may ask for copies of your health information from another professional that you may have seen before.

We may use your health information within our office or disclose your health information outside of our office for PAYMENT purposes. Some examples are:
* When our staff asks you about health or
vision care plans that you may belong
to, or about other sources of payment
for our services.
* When we prepare bills to send to you or
your health or vision care plan.
* When we process payment by credit card
and when we try to collect unpaid
amounts due.
* When bills or claims for payment are
mailed, faxed, or sent by computer to
you or your health or vision plan.
* When we occasionally have to ask a
collection agency or attorney to help
us with unpaid amounts due.

We use and disclose your health information for HEALTHCARE OPERATIONS in a number of ways. Health care operations means those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matter, to develop business plans, and for outside storage of our records.

APPOINTMENT REMINDERS

We may call to remind you of scheduled appointments. We may also call to notify you of other treatments or services available at our office that might help you.

USES & DISCLOSURES WITHOUT AN AUTHORIZATION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never happen at our office at all. Such uses or disclosures are:

* A state or federal law that mandates
certain health information be reported
for a specific purpose.
* Public health purposes, such as conta-
gious disease reporting, investigation
or surveillance; and notices to and
from the 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 over-
sight activities, such as for the
licensing of doctors, audits by Medi-
care or Medicaid, or investigation of
possible violations of healthcare laws.
* Disclosures for judicial and admin-
istrative proceedings, such as in
response to subpoenas or orders of
courts or administrative agencies.
* Disclosures for law enforcement pur-
poses, such as to provide information
about someone who is or is suspected
to be a victim of a crime; to provide
information about a crime at our
office; or to report a crime that
happened somewhere else.
* Disclosure to a medical examiner to
identify a dead person or to determine
the cause of death; or to funeral
directors to aid 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
ranking government officials; for
lawful national intelligence activ-
ities; for military purposes; or for
the evaluation and health of members of
the foreign service.
* Disclosures relating to workers' comp-
ensation programs.
* Disclosures to business associates who
perform healthcare operations for us
and who agree to keep your health
information private.

OTHER DISCLOSURES

We will not make any other uses or disclosures
of your health information unless you sign a written AUTHORIZATION FORM. You do not have to sign such a form. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information.

* You can ask us to restrict our uses and
disclosures for purposes of treatment
(except emergency treatment), payment
or healthcare operations. We do not
have to agree to do this, but if we
agree, we must honor the restrictions
that you want. To ask for a restric-
tion, send a written request to ROUND
VALLEY VISION CENTER at the address or
fax shown at the beginning of this
notice.
* You can ask us to communicate with you
in a confidential way, such as by phon-
ing you at work rather than at home,
by using e-mail to your personal email
address. We will accommodate these
requests if they are reasonable, and
if you pay us for any extra cost. If
you want to ask for confidential com-
munications, send aa written request
to ROUND VALLEY VISION CENTER at the
address or fax shown at the beginning
of this notice.
* You can ask to see or to get photo-
copies of your health information. By
law, there are a few limited situations
in which we can refuse to permit access
or copying. Primarily, however, you
will be able to review or have a copy
of your health information within 30
days of asking us. You may have to pay
for photocopies in advance. If we deny
your request, we will send you a
written explanation, and instructions
about how to get an impartial review of
our denial if one is legally required.
By law, we can have one 30-day exten-
sion time for us to give you access or
photocopies of we sent you a written
notice of the extension. If you want
to review or get photocopies of your
health information, send a written re-
quest to ROUND VALLEY VISION CENTER at
the addaress or fax shown at the begin-
ning of this notice.
* You can ask us to amend your health
information if you think that it is in-
correct or incomplete. If we agree, we
will amend the information within 60
days from when you ask us. We will
send the corrected information to per-
sons who we know got the wrong infor-
mation, and others that you specify.
If we do not agree, you can write a
statement of your position, and we will
include it with your health information
along with any rebuttal statement that
we may write. Once your statement of
position and/or rebuttal is included in
your health information, we will send
it along whenever we make a permitted
disclosure of your health information.
By law, we can have one 30-day exten-
sion of time to consider a request for
amendment if we notify you in writing
of the extension. If you want to ask
us to amend your health information,
send a written request, including your
reasons for the amendment, to ROUND
VALLEY VISION CENTER at the address or
fax shown at the beginning of this
notice.
* You can get a list of the disclosures
that we have made of your health in-
formation within the past six years
(or a shorter period if you want),
except disclosures for purposes of
treatment, payment or health care oper-
ations, disclosures made in accordance
with an authorization signed by you,
and some other limited disclosures.
You are entitled to one such list per
year without charge. If you want more
frequent lists, you will have to pay
for them in advance. We will usually
respond to your request within 60 days
of receiving it, but by law we can have
one 30-day extension of time if we no-
tify you of the extension in writing.
If you want a list, send a written
request to ROUND VALLEY VISION CENTER
at the address or fax shown at the be-
ginning of this notice.

OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to ROUND VALLEY VISION CENTER at the address, fax or e-mail shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit ROUND VALLEY VISION CENTER at the address or phone number shown at the beginning of this notice.



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