HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)
Effective date of notice: April 14, 2003
NOTICE OF PRIVACY PRACTICES
James H. Grimes, O.D.
1405 West Harrison Street, Ste 101
Olympia, WA 98502
Office (360) 357-5548
Fax (360) 786-9797
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
GENERAL RULE
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices.
Generally, we cannot use your health information in our office or disclose it outside of our office without your written permission. Sometimes the written permission will be called a consent form, and sometimes it will be called an authorization form. The type of permission form will depend upon the kinds of uses or disclosures that are involved. In some limited situations, the law allows or requires us to disclose your health information without either a written consent or authorization.
USES OR DISCLOSURES WITH CONSENT
We will ask you to sign a consent form allowing us to use and disclose your health information for purposes of treatment, payment, and health care operations of this office. We are allowed to refuse to treat you if you do not sign the consent form.
We use information for treatment purposes, when, for example, we set up an appointment for you, when our technician or doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when doctor prescribes medication, when our staff helps you select and order glasses or contact lenses, and when we show you low vision aids. We may disclose your health information outside of our office for treatment purposes if, for example, 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 to be filled, when we provide a prescription for medication to a pharmacist, or 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 us.
We use your health information for payment purposes when, for example, our staff asks you about health of 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. We may disclose your health information outside of our office for payment purposes when, for example, bills or claims for payment are mailed, faxed, or sent by computer to you or your health of vision plan, or 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 health care 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 manners, to develop business plans, and for outside storage of our records.
USES AND DISCLOSURES WITHOUT CONSENT OR 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 come up at our office at all. Such uses or disclosures are:
· 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 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 oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; 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 or administrative agencies;
· Disclosures for law enforcement purposes, 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 activities; for military purposes; or for the evaluation and health of members of the foreign service;
· Disclosures relating to worker's compensation programs
· Disclosure to business associates who perform health care operations for us and who agree to keep your health information private.
APPOINTMENT REMINDERS
We may call to remind you of your scheduled appointments. We may also call to notify you of other treatments or services available at our office that might help you.
POST CARDS
We may also send post cards to remind you when it is time to schedule an appointment for an eye examination or another treatment.
OTHER DISCLOSURES
\tWe will not make any 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
\tThe 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 health care operations. We do not have to agree to do this, but if we agree, we must honor the restriction that you want. To ask for a restriction, send a written request to Dr. James H. Grimes at the address or fax shown at the beginning of this Notice.
· Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E mail 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 communications, send a written request to Dr. James H. Grimes at the address or fax shown at the beginning of this Notice.
· Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, 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 extension of the time for us to give you access or photocopies if we send you a written notice request to Dr. James H. Grimes at the address or fax shown at the beginning of this Notice.
· Ask us to amend your health information if you think that it is incorrect 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 persons ho we know got the wrong information, 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 our 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 extension 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 Dr. James H. Grimes at the address or fax shown at the beginning of this Notice.
· Get a list of the disclosure that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations 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 you request within 60 days of receiving it, but by law we can have one 30-day extension for time if we notify you of the extension in writing. If you want a list, send a written request to Dr. James H. Grimes at the address or fax at the beginning of the notice.
· Get additional paper copies of this Notice of Privacy Practices upon request, no matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written notice to Dr. James H. Grimes at the address or fax shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
\tBy law, we must abide by 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 for Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web Site.
COMPLAINTS
\tIf 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 message to Dr. James H. Grimes at the address or fax shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION\t
\tIf you want more information about our privacy practices, call or visit Kornmesser Optometry Clinic, Inc., P.S. at the address or phone number shown at the beginning of the Notice.
James H. Grimes, O.D.
1405 West Harrison Street, Suite 101
Olympia, WA 98502
(t) (360) 357-5548
(f) (360) 786-9797
CONSENT TO USE OR DISCLOSE HEALTH
INFORMATION FOR TREATMENT, PAYMENT AND
HEALTH CARE OPERATIONS
\tIn the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.
\tWe have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only include care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; our submission of claims to third-part payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office or from our website at
\tWhen you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form.
\tYou have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment of health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.
\tI HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE FOR MY HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.
\tDates \t\t Signature \t\t\t\t\t\t\t\t
\t\t\t\t Print Name: ____________________________________
\tIf you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
\tRelationship to Patient \t\t\t\t Print Name \t\t\t\t\t
\tSource of Authority
