|
This
notice describes how information about you may be used
and disclosed and how you can get access to this
information.
During
treatment at VitreoRetinal Surgery, doctors, technicians
and other caregivers may gather information about your
medical history and health.
This notice will explain how such information may
be used and shared with others. It will also explain privacy rights regarding this kind of
information.
When
we refer to “you” or “your” in the Notice, we
refer to the patient.
When we refer to types of disclosures of
information to “you”, we mean disclosure to the
patient, the patient’s guardian, or person legally
authorized to receive information about the patient.
Medical
information may be used for the following purposes:
-
Treatment:
We
will use your information to provide,
coordinate, and manage care and treatment.
For example, a physician may share medical
information with another physician for consultation
or a referral
-
Payment:
We will use information to receive payment for the
services we provide.
For example, we will disclose information in
order to submit bills or claims to insurance
companies and Medicare or Medicaid.
-
Health
Care operations:
We will use information for certain activities
related to the functioning of VitreoRetinal Surgery. For example, we may use or disclose information for quality
assurance activities.
-
Appointment
reminders and other health information: We may
use information to call you or send you reminders
about future appointments.
We may also contact you with information
about new or alternative treatments or other health
care services.
-
Fundraising:
We may use information to notify you about
fund-raising campaigns or other charitable events.
-
Family
members or other responsible people:
We may disclose information to people who will be
taking care of you or are responsible for paying
bills, such as other family members. VitreoRetinal
Surgery will only disclose medical information that
these people need to know.
We may also use information to let other
family members or other responsible people know
where you are and what your general medical
condition is. If
you are able to make your own health care decisions,
VitreoRetinal Surgery will ask permission before
using medical information for these purposes.
If you are unable to make health care
decisions, VitreoRetinal Surgery will disclose
relevant medical information to family members or
other responsible people if we feel it is in the
patient’s best interests to do so.
For example, we may provide limited medical
information to allow another family member to pick
up a prescription or x-ray for you.
-
Emergency
conditions:
Under emergency conditions, we may disclose
information about you to the government or other
groups that assist in emergencies or disasters.
-
Other
uses or disclosures:
VitreoRetinal Surgery may disclose or use
information in the following cases: when required by
law; for public health activities; relating to
victims of abuse, neglect, or domestic violence; for
health oversight activities; for judicial and
administrative proceedings to the extent permitted
by law; for law enforcement purposes, as permitted
or required by law; to coroners, medical examiners,
and funeral directors, as permitted by law; for
organ donation purposes; for research purposes under
certain circumstances; to avert a serious threat to
health or safety; for certain specialized government
functions, such as military discharge and national
security and intelligence; and for worker’s
compensation purposes.
-
Research:
Federal law permits VitreoRetinal Surgery, P.A. to
use and disclose medical information about you for
research purposes, either with your specific written
authorization or when the study has been reviewed
for privacy protection by an Institutional Review
Board or Privacy Board before the research begins.
In some cases, researchers may be permitted to use
information in a limited way to determine whether
the study or the potential participants are
appropriate. Minnesota
law generally requires that we get your general
consent before we disclose your health information
to an outside researcher.
We will make a good faith effort to obtain
your consent or refusal to participate in any study,
as required by law, prior to releasing any
identifiable information about you to outside
researchers.
PRIVACY
RIGHTS
-
Restrict
use and disclosure:
You may request that VitreoRetinal Surgery
not use medical information in certain ways or for
certain purposes.
You may also request that VitreoRetinal
Surgery not provide medical information to certain
people.
However, VitreoRetinal Surgery has the right
to refuse your request.
VitreoRetinal Surgery may use or disclose
your medical information in situations requiring
emergency treatment, in which case we will ask the
person(s) who receives the information not to
further use or disclose the information.
-
Provide
confidentiality:
You may request that VitreoRetinal Surgery
provide you with your medical information in a
confidential manner. For example, you can request
that we send appointment reminders, bills, and other
mailings to a different address or that we notify
you of this kind of information in another way, such
as by telephone call.
You must make this request in writing and
specify another address or means of communication. We must agree to your written request. We may also ask you to give us information about how you will
pay your bills.
-
Inspection
and copy:
You may ask to see and copy your medical
records, unless that information is protected by
law. You
must make these requests in writing.
If your request to look at or copy your
medical records is denied, you have the right to
have the denial reviewed by a health care
professional. We
will act upon your request within 30 days and may
charge you a legally acceptable amount for copying
costs.
-
Change
information or amend medical records: You
may ask us to change information in your medical
records. If
your request is denied, you can write a statement of
disagreement with the denial that we will keep with
your medical information.
-
Accounting
of disclosures: You may ask us to provide you with information about certain
disclosures of your medical information we made in
the past. Requests
for accountings will not be made prior to April 14,
2003. Your
request can go back six years but will not include
disclosures made prior to April 14, 2003.
-
Paper
copy:
If you have received this notice of the
medical information privacy rights electronically,
you may ask us to provide you with a paper copy.
-
Privacy
violations: If you feel your medical information
privacy rights have been violated, you may file a
complaint with the Secretary of Health and Human
Services and/or with VitreoRetinal Surgery and you
will not be retaliated against for filing a
complaint.
The
U.S. Dept. of Health and Human Services
200 Independence Ave. S.W.
Washington, D.C. 20201
(202) 619-0257
Toll free: 1-877-696-6775
Electronic: HHS.Mail@hhs.gov
VitreoRetinal
Surgery privacy official: You may contact the designated privacy official at
VitreoRetinal Surgery.
Privacy
Officer: Mary Nordenstrom
Address: 7760
France Ave. S. #310
Minneapolis, MN 55435
Phone:
952-259-3448
The effective date of this notice is April 14, 2003. VitreoRetinal Surgery is required by law to maintain the
privacy of protected health information and to provide
individuals with this notice of its legal duties and
privacy practices with respect to health information.
VitreoRetinal Surgery is required to abide by the
terms of the notice currently in effect. VitreoRetinal Surgery reserves the right to change the terms
of this notice and to make new notice provisions
effective for all protected health information
maintained by VitreoRetinal Surgery.
If the terms of this notice are changed,
VitreoRetinal Surgery will provide individuals with a
revised notice at the time of treatment, or upon
request, by posting the revised notice in designated
locations at VitreoRetinal Surgery.
|
|
