Notice of Privacy Practices

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.

You may also download a pdf of the notice here.

This Notice describes the privacy practices of Eye Health Services (“we” or “us”), including:

  • All healthcare professionals allowed to enter or access information in your medical record
  • All employees and physicians and other health care professionals that provide services in our facilities with access to your medical or billing records or health information about you (“Protected Health Information” or “PHI”).
  • Any volunteer authorized to help you while you are a patient at Eye Health Services.

We understand that your health information is personal and we are committed to protecting your privacy. In addition, we are required by law to maintain the privacy of your Protected Health Information, to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information, and to notify you in the event of a breach of your unsecured Protected Health Information. When we use or disclose Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

In certain situations, which we will describe in Sections IV below, we must obtain your written consent or authorization in order to use and/or disclose your Protected Health Information. However, unless the Protected Health Information is Highly Confidential Information (as defined in Section IV.B below) and the applicable law regulating such information imposes special restrictions on us, we may use and disclose your Protected Health Information without your written authorization for the following purposes:

A. Use For Treatment, Payment and Health Care Operations.

We may use (but not disclose to a third party) your PHI in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:

  • Treatment. We use and disclose your Protected Health Information to provide treatment and other services to you—for example, to diagnose and treat your injury or illness, or to consult with your physician about your diagnosis, injury or illness. In addition we may contact you to provide appointment reminders, testing results and insurance items among others. We may use your information to direct or recommend alternative treatments, therapies, health care providers, or settings of care to you or to describe a health-related product or service. We may also disclose Protected Health Information to other providers involved in your treatment.
  • Payment. We may use and disclose your Protected Health Information to obtain payment for health care services that we provide to you—for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of your health care (“Your Payor”) to verify that Your Payor will pay for the health care. We may also disclose Protected Health Information to your other health care providers when such Protected Health Information is required for them to receive payment for services they render to you.
  • Health Care Operations. We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our physicians, nurses and other health care professionals. We may disclose Protected Health Information to our Customer Relations in order to resolve any complaints you may have and ensure that you are satisfied with our services.
  • Disclosure to Relatives, Close Friends and Other Caregivers.
    We may use or disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.

    If you are incapacitated or in an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend in such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your health care or payment related to your health care.

    We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

B. As Required by Law. We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.

C. Public Health Activities. We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

D. Victims of Abuse, Neglect or Domestic Violence. We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.

E. Health Oversight Activities. We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

F. Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

G. Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

H. Decedents. We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.

I. Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

J. Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

K. Specialized Government Functions. We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

L. Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

For any purpose other than the ones described above in Section III, we only use or disclose your Protected Health Information when you give us your written authorization.

A. Marketing. We must obtain your written authorization prior to using your Protected Health Information for purposes that are marketing under the HIPAA privacy rules. For example, we will not accept any payments from other organizations or individuals in exchange for making communications to you about treatments, therapies, health care providers, settings of care, case management, care coordination, products or services unless you have given us your authorization to do so or the communication is permitted by law.

We may provide refill reminders or communicate with you about a drug or biologic that is currently prescribed to you so long as any payment we receive for making the communication is reasonably related to our cost of making the communication. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining your written authorization.

B. Sale of Protected Health Information. We will not make any disclosure of Protected Health Information that is a sale of Protected Health Information without your written authorization.

C. Uses and Disclosures of Your Highly Confidential Information. Federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including: (1) your HIV/AIDS status; (2) genetic testing information; (3) confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor, or other allied mental health professional or human services professional; (4) substance abuse (alcohol or drug) treatment or rehabilitation information; (5) venereal disease information; (6) abortion consent form(s); (7) mammography records; (8) family planning services; (9) treatment or diagnosis of emancipated minors; (10) mental health community program records; and (11) research involving controlled substances. In order for us to disclose your Highly Confidential Information for a purpose related to treatment, payment, or health care operations, we must obtain your specific written consent unless we are otherwise permitted by law to make such disclosure.

In addition, if you are an emancipated minor, certain information relating to your treatment or diagnosis may be considered “Highly Confidential Information” and as a result will not be disclosed to your parent or guardian without your consent.

Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered. Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification.

Please note that if you are a parent or legal guardian of an emancipated minor, certain portions of the emancipated minor’s medical record (or, in certain instances, the entire medical record) may not be accessible to you.

A. For Further Information: Complaints.

If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to PHI, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Additional Restrictions.

You may request restrictions on our use and disclosure of PHI: (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. All requests for such restrictions must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction unless the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service for which you have paid us out of pocket in full. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.

C. Right to Receive Confidential Communications.

You may request, and we will accommodate any reasonable written request, to receive PHI by alternative means of communication or at alternative locations.

D. Right to Inspect and Copy Your Health Information.

You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Officer. If you request copies, we will charge you $0.25 for each page. We will also charge you for our postage costs, if you request that we mail the copies to you.

E. Right to Revoke Your Authorization.

You may revoke your Authorization, your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified below. A form of Written Revocation is available upon request from the Privacy Officer.

F. Right to Amend Your Records.

You have the right to request that we amend your Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

G. Right to Receive An Accounting of Disclosures.

Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, we will charge you $0.25 per page] of the accounting statement.

H. Right to Receive Paper Copy of this Notice.

Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

A. Effective Date.

This Notice is effective on September 1, 2014.

B. Right to Change Terms of this Notice.

We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in waiting areas of the Practice and on our Internet site at www.eyehealthservices.com. You may also obtain any revised notice by contacting the Privacy Officer.

You may contact the Privacy Office at:

Privacy Office
Eye Health Services
1900 Crown Colony Drive, Suite 301
Quincy, MA 02169


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