Notice of Use and Disclosure of Protected Health Information
Effective Date: 01/01/2015
If you have questions or complaints after reading this notice feel free to contact staff at Venice Optometry and we’ll do our best to accommodate your needs.
11100 S. Auto Mall Drive | Sandy, UT 84070
Phone: (801) 790-0012 | Fax: (801) 790–0013
Email: Dr.Arici@VeniceOptometry.com
GENERAL INFORMATION ABOUT THIS NOTICE
Venice Optometry is committed to maintaining the confidentiality of your private health information in compliance with HIPAA regulations. This form is to inform you of our efforts to safeguard your health information from improper or unnecessary use or disclosure.
This Notice only applies to individuals who receive service from Venice Optometry. We are independent, contracted, optometrists located inside of the Sandy Costco.
WHAT IS PROTECTED?
The federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as modified by the Health Information Technology for Economic and Clinical Health Act (“HITECH”), requires that Venice Optometry safeguard health information about "protected health information," or "PHI," created, received, maintained or transmitted in the course of providing services. PHI is health information that can be used to identify you and that relates to (1) your physical or mental health condition, (2) the provision of health care to you, or (3) payment for your health care. Your prescriptions and vision test results as well as any other related information you provide our staff are all examples of PHI.
The remainder of this Notice describes our rules with respect to PHI created, received, maintained or transmitted Venice Optometry and your rights regarding that information.
Use and Disclosure of you Patient Health Information by Venice Optometry
We may use or disclose PHI in the following ways:
• To refer you to another health care provider if needed for your treatment. For example, we may discuss the condition of your eye with specialist if we feel that we don't have the resources or expertise to handle your condition internally.
• To bill you for health care services or products. Venice Optometry may use and disclose your PHI to bill and to accept payment for services rendered.
• For the administration and operation of our office. Venice Optometry employees will have access to your information as well as Optical employees of Costco solely for the purpose of providing you with products related to your eye exam.
• To a family member, friend, or other person involved in your health care if you are present and you do not object to the sharing of PHI or in the event of an emergency or to individuals you expressly tell us this information can be released to, such as a spouse. We will also release PHI for minors to the parents or guardians of the child.
• To comply with an applicable federal, state, or local law, including, for example, workers' compensation programs established by law.
• For public health reasons, including to a public health authority for the prevention or control of disease, injury or disability; to a proper government or health authority to report child abuse or neglect; to report reactions to medications or problems with products regulated by the Food and Drug Administration; to notify individuals of recalls of medication or products they may be using; or to notify a person who may have been exposed to a communicable disease or who may be at risk for contracting or spreading a disease or condition.
• To report a suspected case of abuse, neglect or domestic violence, as permitted or required by applicable law.
• To comply with health oversight activities, such as audits, investigations, inspections, licensure actions, and other government monitoring and activities related to health care provision or public benefits or services.
• To the U.S. Department of Health and Human Services to demonstrate our compliance with HIPAA.
• To respond to an order of a court or administrative tribunal, such as a court-ordered warrant, subpoena or summons, grand jury subpoena, or administrative subpoena or other request.
• To respond to a subpoena, warrant, summons or other legal request if sufficient safeguards, such as a protective order in the case of a private lawsuit, are in place to maintain PHI privacy.
• To a law enforcement official for a law enforcement purpose as required by law.
• For purposes of public safety or national security.
• To allow a coroner or medical examiner to identify you or determine your cause of death.
• To allow a funeral director to carry out his or her duties.
• To respond to a request by military command authorities if you are or were a member of the armed forces.
We will use the minimum amount of PHI necessary to perform these tasks. We also require our business associates to limit any use or disclosure of your PHI to the minimum necessary amount. If an applicable state or federal law provides greater health information privacy protections than HIPAA, we will comply with the stricter law.
Finally, if we or one of our business associates create, receive, maintain or transmit your PHI in an unsecured manner (such as in paper form or in an unencrypted electronic form) and a breach occurs, we will notify you.
OTHER USES AND DISCLOSURES OF PHI
Before we use or disclose PHI for any purpose other than as described above, we must obtain your written authorization, including uses and disclosures for:
• Marketing. Marketing means making a communication about a product or service that encourages you to purchase or use the product or service. Marketing does not include our face-to-face interactions with you or reminders or other communications we might have with or send to you about our office.
• Receiving direct or indirect payment in exchange for providing the information. However, the disclosure of your PHI to a health insurer in order to receive payment for products or services we provide to you is permissible.
You may revoke your authorization, in writing, at any time. If you revoke your authorization, Venice Optometry will no longer use or disclose PHI except as described above (or as permitted by any other authorizations that have not been revoked). However, please understand that we cannot retrieve any PHI disclosed to a third party in reliance on your prior authorization.
YOUR RIGHTS
Federal law provides you with certain rights regarding PHI that pertains to you. Parents of minor children who are customers of Venice Optometry and other individuals with legal authority to make health decisions for customers of Venice Optometry may exercise these rights on behalf of such customers, consistent with state law.
• Right to request restrictions: You have the right to request a restriction or limitation on Venice Optometry’s use or disclosure of PHI. The law does not require Venice Optometry to agree to your request unless the request relates to a health care item or service for which you have paid in full out-of-pocket and you have requested in advance that we do not disclose the item or service to your health plan for the purpose of obtaining payment. We will honor such a request provided that such disclosure is not otherwise required by law. If you want to request such a restriction concerning an item or service that you pay for in full out-of-pocket, you must submit the request in advance of your purchase.
Your request must specify: (i) the PHI you want to limit; (ii) how you want Venice Optometry to limit the use, disclosure, or both of that PHI; and (iii) to whom you want the restrictions to apply. We will honor the restriction until you agree to terminate the restriction or until we notify you that we are terminating the restriction on a going-forward basis.
• Right to receive confidential communications: You have the right to request that Venice Optometry communicate with you about PHI at a new address or by different means if you believe that communication through normal business practices could endanger you. You may submit a written request for confidential communications to our office.
• Right to obtain a copy of PHI: You have the right to review and obtain a copy of PHI that is contained in medical or billing records that Venice Optometry maintains or other records that Venice Optometry uses to make decisions about you. However, we will not give you access to PHI records created in anticipation of a civil, criminal or administrative action or proceeding. We will also deny your request to inspect and copy PHI if a licensed health care professional hired by Venice Optometry has determined that giving you the requested access is reasonably likely to endanger the life or physical safety of you or another individual or to cause substantial harm to you or another individual, or that the record makes references to another person (other than a health care provider), and that the requested access would likely cause substantial harm to the other person. If your request to access PHI is denied, you may have that decision reviewed. A different licensed health care professional chosen by Venice Optometry will review the request and denial, and we will comply with the health care professional's decision.
You may make a request to review or obtain a copy of PHI at our office inside the Sandy Costco. We may charge you a fee to cover the costs of copying, mailing or other supplies directly associated with your request. You will be notified of any costs before you incur any expenses.
• Right to amend PHI: You have the right to request an amendment of PHI if you believe the information that Venice Optometry has about you is incorrect or incomplete. You have this right as long as PHI is maintained by Venice Optometry. We will correct any mistakes if we created the PHI or if the person or entity that originally created the PHI is no longer available to make the amendment. Amendments involving the addition of information to Venice Optometry health records may be made at the Sandy Location.
• Right to receive an accounting of disclosures of PHI: You have the right to request a list of certain disclosures of PHI by Venice Optometry. The accounting will not include certain disclosures. For example, the accounting would not include disclosures we made to you or in response to your written authorization. We will notify you at the time we provide the accounting of the disclosures that are not included. Your first request for an accounting within a 12-month period will be free. We may charge you for costs associated with providing you additional accountings. We will notify you of the costs involved, and you may choose to withdraw or modify your request before you incur any expenses. You may submit a written request for an accounting of disclosures of PHI by submitting a request that includes (i) the time period for the accounting, which may not be longer than required by federal law; and (ii) the form (e.g., electronic, paper) in which you would like the accounting.
• Right to file a complaint: If you believe your rights have been violated, you should let us know immediately. We will take steps to remedy any violations of Venice Optometry's privacy policy or of this Notice. You may file a formal complaint with us and/or with the United States Department of Health and Human Services at the address below. You should attach any documents or evidence that supports your belief that your privacy rights have been violated. We take your complaints very seriously. Venice Optometry policy and federal law prohibit retaliation against any person for filing such a complaint.
ADDITIONAL INFORMATION ABOUT THIS NOTICE
• Changes to this Notice: We reserve the right to change Venice Optometry’s privacy practices as described in this Notice. Any change may affect the use and disclosure of PHI already maintained by Venice Optometry, as well as any of PHI that Venice may receive or create in the future. If there is a material change to the terms of this Notice, revised Notices will be made available at www.vencieoptometry.com
• Acknowledgement: When first delivering this Notice to you we will ask you to sign an acknowledgement that you were provided a copy of this Notice.
U.S. Department of Health & Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
www.hhs.gov/ocr/hipaa/
