NASHUA EYE ASSOCIATES,
P.A.
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.
A. OUR COMMITMENT TO
YOUR PRIVACY
Our Practice is dedicated to maintaining the
privacy of your Protected Health Information (PHI). “Protected Health Information” is information
about you, including demographic information, that may identify you and that
relates to your past, present or future physical or mental health or condition
and related health care services. In
conducting our business, we will create records regarding you and the treatment
and services we provide to you. We are
required by law to maintain the confidentiality of health information that
identifies you. We are also required by
law to provide you with this notice of our legal duties and the privacy
practices that we maintain in our practice concerning your PHI. By Federal and State law, we must follow the
terms of the Notice of Privacy Practice that we have in effect at the
time.
We realize that these laws are complicated, but we
must provide you with the following important information:
·
How we may use and
disclose your Protected Health Information (PHI)
·
Your privacy rights in
your PHI
·
Our obligation
concerning the use and disclosure of your PHI
The terms of this notice apply to all records
containing your PHI that are created or retained by our practice. We reserve the right to change or amend this
Notice of Privacy Practice at any time. Any revision or amendment to this
notice will be effective for all of your records that our practice has created
or maintained in the past, and for any of your records that we may create or
maintain in the future. Our practice
will post a copy of our current Notice in our offices in a visible location at
all times. You may request a copy of our
most current Notice at any time by calling the office and requesting that a
revised copy be sent to you in the mail or asking for one at the time of your
next appointment.
B. HOW
WE MAY USE AND DISCLOSURE PHI ABOUT YOU
Your protected health information may be used and
disclosed by your physician, our office staff and others outside of our office
that are involved in your care and treatment for the purpose of providing
health care services to you. Your protected health information may also be used
and disclosed to pay your health care bills and to support the operation of the
physician’s practice.
The following categories describe the different
ways in which we may use and disclose your PHI.
Treatment: We will use and disclose your protected health information
to provide, coordinate, or manage your health care and any related services.
This includes the coordination or management of your health care with a third
party. For example, we would disclose your protected health information, as
necessary, to a home health agency or nursing home that provides care to you,
or to a pharmacy when we order a prescription for you. We will also disclose
protected health information to other physicians who may be treating you.
For example, your protected health information may
be provided to your Primary Care Doctor who oversees your general medical care
to ensure that the physician has the necessary information to properly
coordinate your care.
In addition, we may disclose your protected health
information from time-to-time to another physician or health care provider
(e.g., another specialist, laboratory, hospital, or surgery center) who, at the
request of your physician, becomes involved in your care by providing
assistance with your health care diagnosis or treatment. We may also disclose
your PHI to others who are known to assist in your care, such as your spouse,
children or parents.
Payment: Your protected health information will be used in order to
bill and obtain payment for the health care services and items you may receive
from us. This may include certain activities that your health insurance plan
may undertake before it approves or pays for the health care services we
recommend for you such as; making a determination of eligibility or coverage
for insurance benefits, reviewing services provided to you for medical
necessity, and undertaking utilization review activities. For example,
obtaining approval for a hospital stay may require that your relevant protected
health information be disclosed to the health plan to obtain approval for the
hospital admission. We may also use and disclose your PHI to obtain payment
form third parties that may be responsible for such costs, such as family
members. Also, we may use your PHI to bill you directly for services and
items.
Healthcare Operations: We may use or disclose your protected health information
in order to support the business activities of our practice. These activities
include, but are not limited to, quality assessment activities, employee review
activities, licensing, or to conduct cost-management and business planning
activities for our practice.
We will also call you by name in the waiting room
when your physician is ready to see you.
We may use and disclose your PHI to contact you as a reminder that you
have an appointment for medical care with the Practice or that you are due to
receive periodic care from the practice. If we are unable to reach you
personally, we may leave messages for you regarding upcoming appointments or
instructions regarding your appointment, which could potentially be received or
intercepted by others. Our practice may
use and disclose your PHI to inform you of potential treatment options or
alternatives. We may also send you our
newsletter about our practice and the services we offer.
We will share your protected health information
with third party “business associates” that perform various activities (e.g.,
billing clearinghouse, answering service, etc.) for the practice. Whenever an
arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract that contains terms that will protect the privacy of your protected
health information.
Unless you object, we may disclose to a member of
your family, a relative, a close friend or any other person you identify, your
protected health information that directly relates to that person’s involvement
in your health care. If you are unable to agree or object to such a disclosure,
we may disclose such information as necessary if we determine that it is in
your best interest based on our professional judgment. We may use or disclose
protected health information to notify or assist in notifying a family member,
personal representative or any other person that is responsible for your care,
general condition or death.
Other Permitted and Required Uses and
Disclosures That May Be Made Without Your Consent, Authorization or Opportunity
to Object
We may use or disclose your protected health
information in the following situations without your authorization. These
situations include:
Required By Law: We may use or disclose your protected health information
when required to do so by federal, state, or local law.
Emergency
Situations: We may disclose PHI about you to an
organization assisting in a disaster relief effort or in an emergency situation
so that your family can be notified about your condition, status and location.
Public Health: Law or public policy may require us to disclose medical
information about you for public health activities. These activities generally include: preventing or controlling disease, injury or
disability; maintaining vital records such as births and deaths; reporting
child abuse or neglect; reporting reactions to medications or problems with
products; notifying people of recalls of products they may be using; notifying
a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; notifying the appropriate
government authority if we believe a patient has been a victim of abuse,
neglect or domestic violence. However,
we will only disclose this information if you agree or when required or
authorized by law to disclose this information.
Investigation and Government Activities: We may disclose protected health information to a health
oversight agency for activities authorized by law, such as audits,
investigations, and inspections. Oversight agencies seeking this information
include government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights laws.
Lawsuits and Legal Proceedings: If you are involved in a lawsuit or a dispute, we may
disclose medical information about you in response to a court or administrative
order. This is particularly true if you
make your health an issue. We may also
disclose medical information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute. We shall attempt in these cases to tell you
about the request so that you may obtain an order protecting the information
requested if you so desire. We may also
use such information to defend ourselves or any member of our Practice in any
actual or threatened action.
Law Enforcement: We may release medical information if asked to do so by a
law enforcement official: 1) Regarding a
crime victim in certain situations, if we are unable to obtain the person’s
agreement; 2) Concerning a death we believe has resulted from criminal conduct;
3) Regarding criminal conduct at our offices; 4) In response to a warrant,
summons, court order, subpoena or similar legal process; 5) To identify/locate
a suspect, material witness, fugitive or missing person; 6) In an emergency, to
report a crime (including the location or victim(s) of the crime, or the
description, identity or location of the perpetrator
Research: We may disclose your protected health information to
researchers when their research has been approved by an institutional review
board that has reviewed the research proposal and established protocols to
ensure the privacy of your protected health information.
Serious
Threats to Health or Safety: We may use and disclose PHI about you when
necessary to reduce or prevent a serious threat to your health and safety or
the health and safety of the public or another individual. Any disclosure would only be made to someone
able to help prevent the threat.
Military Activity and National Security: We may use or disclose protected health information of
individuals who are members of U.S. or foreign military forces (including
veterans) if required by the appropriate authorities. We may also disclose your protected health
information to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.
Workers’ Compensation: Your protected health information may be disclosed by us
as authorized to comply with workers’ compensation laws and other similar
legally established programs.
Inmates: We may use or disclose your protected health information
if you are an inmate of a correctional facility and your physician created or
received your protected health information in the course of providing care to
you.
USES AND
DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN
AUTHORIZATION
Other uses and disclosures of your protected
health information not covered by this notice or the laws that apply to us will
be made only with your written authorization, unless those uses can be
reasonably inferred from the intended uses above. You may revoke this authorization, at any
time, in writing. After you revoke your
authorization, we will no longer use or disclose your PHI for the reasons
described in the authorization. You
understand that we are unable to take back any disclosures we have already made
with your permission, and that we are required to retain our records of the
care that we provided to you.
C. Your Rights Regarding your PHI
You have the following rights regarding the PHI
that we maintain about you:
You have the right to inspect and copy your
protected health information. You have
the right to inspect and obtain a copy of protected health information that may
be used to make decisions about your care, including your own medical and
billing records. Upon proof of appropriate legal relationship, records of
others related to you or under your care (guardian or custodial) may also be
disclosed.
To inspect or obtain a copy of your PHI, you must
submit your request in writing to our Medical Records Supervisor, 5 Coliseum
Avenue, Nashua, NH 03063. Our practice
charges a fee for the costs of copying, mailing, labor and supplies associated
with your request.
Under federal law, however, you may not inspect or
copy the following records; psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or administrative
action or proceeding. If you are denied access to medical information, you may
request a review of the denial. Another
licensed health care professional chosen by us will conduct the review. The person conducting the review will not be
the person who denied your request. We
will comply with the outcome and recommendations from that review.
You have
the right to amend your medical record. You may ask us to amend your health information if you
believe it is incorrect or incomplete, and you may request an amendment for as
long as the information is kept by or for our practice. To request an amendment, your request must be
made in writing and submitted to our Medical Records Supervisor, 5 Coliseum
Avenue, Nashua, NH 03063. You must provide us with a reason that
supports your request for amendment.
The amendment must be dated, signed by you and notarized. Our practice will deny your request for an
amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your
request if you ask us to amend information that is, in our opinion: (a) accurate and complete; (b) not part of
the PHI kept by or for the practice; (c) not part of the PHI which you would be
permitted to inspect and copy; or (d) not created by our practice, unless the
individual or entity that created the information is not available to amend the
information. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and
we may prepare a rebuttal to your statement and will provide you with a copy of
any such rebuttal.
You have the right to request a restriction
of your protected health information.
This means you may ask us not to use or disclose any part of your protected
health information for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your protected health
information not be disclosed to family members or friends who may be involved
in your care. We are not required to agree to your request and we may not be
able to comply with your request. If your physician believes it is in your best
interest to permit use and disclosure of your protected health information,
your protected health information will not be restricted. If your physician does
agree to the requested restriction, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information is necessary
to treat you. With this in mind, please discuss any restriction you wish to
request with your physician. In order to request a restriction in our use or
disclosure of your PHI, you must make your request in writing to our Medical
Records Supervisor, 5 Coliseum Avenue, Nashua, NH 03063.
Your request must describe in a clear and concise fashion:
a.
The information you
want limited or restricted;
b.
Whether you are
requesting to limit our practice’s use, disclosure or both; and
c.
To whom you want
limits to apply (i.e. children, spouse etc.)
You have the right to request confidential
communications. You
have the right to request that we communicate with you about medical matters in
a certain way or at a certain location.
For example, you may ask that we only contact you at home, rather than
at work. Depending upon the request, we
may place certain conditions on the accommodation such as asking you for
information as to how payment will be handled or specification of an
alternative address or other method of contact. In order to request a type of
confidential communication, you must make a written request to our Medical
Records Supervisor at 5 Coliseum Avenue, Nashua, NH 03063, specifying the requested method of
contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You
do not need to give a reason for your request.
You have the right to an accounting of
certain disclosures. This right
applies to disclosures for purposes other than treatment, payment or healthcare
operations as described in this Notice of Privacy Practices. In order to obtain
an accounting of disclosures, you must submit your request in writing to our
Medical Records Supervisor, 5 Coliseum Avenue, Nashua, NH 03063.
All requests for an “accounting of disclosures” must state a time
period, which may not be longer than six (6) years from the date of disclosure
and may not include dates before April 14, 2003. We will notify you of the costs involved and
you may withdraw your request before you incur any costs.
You have the right to obtain a paper copy of
this notice. You are entitled to receive a
paper copy of our notice of privacy practices.
You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact our
Medical Records Supervisor at 5 Coliseum Avenue, Nashua, NH 03063.
D. Complaints
If you believe your privacy rights have been
violated, you may file a complaint with our Practice or with the Secretary of
Health and Human Services. To file a complaint with our Practice, contact our
Practice Administrator at 5 Coliseum Avenue, Nashua, NH 03063.
All complaints must be submitted in writing. You will not be penalized for filing a
complaint.
If you have any questions regarding this notice or
our health information privacy policies, please contact our Practice
Administrator at 5 Coliseum Avenue, Nashua, NH 03063, or by calling 603-882-9800.
This notice was published and becomes effective on
April 14, 2003.