Privacy Notice
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "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.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your doctor, 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 our practice.
Following are examples of the types used and disclosures of your protected health care information that our practice is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types used and disclosures that may be made by our office once you have provided consent.
Treatment: In the course of your treatment it is necessary to 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 that has already obtained your permission to have access to your protected health information. In providing care to you, we may need to disclose your protected health information from time-to-time to another doctor or health care provider (e.g., a specialist or laboratory) who, at the request of your doctor of optometry, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your doctor of optometry.
For example, with your permission, your protected health information may be provided to a surgeon to whom you have been referred to ensure that the surgeon has the necessary information to diagnose and/or treat you.
Payment: Your protected health information will be used, as required, to obtain payment for your health care services. 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 eligiblity or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
For example, obtaining approval for eyewear, may require a letter explaining your diagnosis. This will require the release of your protected health information. When we submit claim forms to your third party payor /insurance company, we will also be required to release your protected health information.
Healthcare Management: We may use or disclose, as-needed, 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, training of healthcare students, licensing, internal auditing, and conducting or arranging for other business activities.
For example, in addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
Outside Business Associates: We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) 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.
Information and Marketing: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about our practice and services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from your doctor, as necessary, in order to contact you to provide information on your condition or to recall you for future appointments. If you do not want to receive these materials, please contact our Privacy Contact and request that these not be sent to you.
Uses and Disclosures of Protected Health Information Based Upon
Your Written Authorization
All additional requests for healthcare information release, other than those exempted uses listed in this document including those required by law, will be made only with your written authorization. You may revoke this authorization, at any time, in writing, except to the extent that your doctor or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosure That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your doctor may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involed in Your Healthcare: 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 of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosure to family or other individuals involved in your health care.
For example: Your doctor might explain to a patient's caregiver when to administer medication to your eyes.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your doctor or another doctor in the practice is required by law to treat you and the doctor has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.
For example: If a patient suffers an emergency situation in the office, it may be necessary for the doctor or staff to use or release information such as protected health information to provide emergency care.
Communication Barriers: We may use and disclose your protected health information if your physician or another doctor in the practice attempts to obtain consent from you, but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
For example: In the case of a mentally handicapped adult who presents for an examination but is unable to communicate with the doctor, the doctor can treat the patient if he determines that the patient intends to consent.
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 consent or authorization. The situations include:
Required By Law: We may use or disclose your protected health information to the extent that the law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We are required by law to disclose your protected health information for public health activities and purposed to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. For example: Indiana law requires the reporting of all new cases of blindness to the State Board of Health.
Communicable Diseases: We may disclose your protected health information. If authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Government Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations to the extent required by law. 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. For Example: Medicare routinely does sample audits of patient records that require a copy of your record to be released to the auditors.
Abuse or Neglect: State laws may require disclosure of protected health information to a public health authority that is authorized by law to receive reports of child abuse, domestic violence or neglect. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to an agency, person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls to make repairs or replacements, or to conduct post marketing surveillance, as required. For example, an adverse reaction to a new drug would require reporting to the appropriate drug side effect registry.
Legal Actions: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal ( to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice's premises) and it is likely that a crime has occurred. Indiana Law sets specific limits on what can be released.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. For example: protected health information may be used and disclosed for eye donation purpose.
Research: We may release protected health information to reseachers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Millitary Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health info of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of the foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
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 doctor created or received your protected health information in the course of providing care to you.
Enforcement Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Your Rights to Privacy of Health Information
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise the rights.
Inspection/ Copy of Your Record: You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in our practice for as long as we maintain these records. These records include both clinical information and business activities related to your care. Under federal law, however, you may not view or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. A decision to deny access may be reviewed in some cases.
Requests to Further Restrict Disclosure: You have the right to request further restriction of your protected health information. This means you may ask us not to use or disclose parts 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 or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to who you want the restriction to apply. The practice retains the right by law to release required information for billing purposes.
Your doctor of optometry may not agree to a restriction that you may request. If your doctor 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 doctor does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by initially sending a letter to:
Brownsburg Family Eye Care, P.C.
P.O. Box 809
Brownsburg, IN 46112
Attn: Sarah
(317)852-4741
Sending this letter does not indicate that your request will be granted. If the request is agreed to in full or part, you will receive a letter granting such restrictions.
Request Alternate by Alternate Methods or Location: You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Administrator. For example, if you do not wish for information sent to an address where another individual might have access to it, you have a right to request an alternative location to receive communications.
Amending Your Records: You may have the right to have your doctor amend your protected health information. This means you may request an amendment of protected health information about you in our records for as long as we maintain this information. In certain cases, we may deny your request for an amendment. 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. Please contact our Administrator, if you have questions about amending your medical record.
For example: Your records may contain a medical history note that you had been diagnosed with chronic fatigue syndrome, but now you have bee diagnosed with multiple sclerosis and you would like the record corrected.
Right to Record of Information Disclosures: You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to personal care givers, family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that have occurred after April 14, 2003, but not more retroactive than six years. The right to receive this information is subject to certain exception, restrictions and limitations.
Right to Privacy Statement: You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
Your Recourse for Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact us for further information about the complaint process.
Brownsburg Family Eye Care, P.C.
P.O. Box 809
Brownsburg, IN 46112
Attention: Sarah
(317)852-4741
This notice was published on 2/19/2003 and all provision become effective by Federal Law on April 14, 2003. It remains in effect until modified by our practice.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your doctor, 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 our practice.
Following are examples of the types used and disclosures of your protected health care information that our practice is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types used and disclosures that may be made by our office once you have provided consent.
Treatment: In the course of your treatment it is necessary to 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 that has already obtained your permission to have access to your protected health information. In providing care to you, we may need to disclose your protected health information from time-to-time to another doctor or health care provider (e.g., a specialist or laboratory) who, at the request of your doctor of optometry, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your doctor of optometry.
For example, with your permission, your protected health information may be provided to a surgeon to whom you have been referred to ensure that the surgeon has the necessary information to diagnose and/or treat you.
Payment: Your protected health information will be used, as required, to obtain payment for your health care services. 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 eligiblity or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
For example, obtaining approval for eyewear, may require a letter explaining your diagnosis. This will require the release of your protected health information. When we submit claim forms to your third party payor /insurance company, we will also be required to release your protected health information.
Healthcare Management: We may use or disclose, as-needed, 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, training of healthcare students, licensing, internal auditing, and conducting or arranging for other business activities.
For example, in addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
Outside Business Associates: We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) 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.
Information and Marketing: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about our practice and services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from your doctor, as necessary, in order to contact you to provide information on your condition or to recall you for future appointments. If you do not want to receive these materials, please contact our Privacy Contact and request that these not be sent to you.
Uses and Disclosures of Protected Health Information Based Upon
Your Written Authorization
All additional requests for healthcare information release, other than those exempted uses listed in this document including those required by law, will be made only with your written authorization. You may revoke this authorization, at any time, in writing, except to the extent that your doctor or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosure That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your doctor may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involed in Your Healthcare: 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 of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosure to family or other individuals involved in your health care.
For example: Your doctor might explain to a patient's caregiver when to administer medication to your eyes.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your doctor or another doctor in the practice is required by law to treat you and the doctor has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.
For example: If a patient suffers an emergency situation in the office, it may be necessary for the doctor or staff to use or release information such as protected health information to provide emergency care.
Communication Barriers: We may use and disclose your protected health information if your physician or another doctor in the practice attempts to obtain consent from you, but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
For example: In the case of a mentally handicapped adult who presents for an examination but is unable to communicate with the doctor, the doctor can treat the patient if he determines that the patient intends to consent.
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 consent or authorization. The situations include:
Required By Law: We may use or disclose your protected health information to the extent that the law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We are required by law to disclose your protected health information for public health activities and purposed to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. For example: Indiana law requires the reporting of all new cases of blindness to the State Board of Health.
Communicable Diseases: We may disclose your protected health information. If authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Government Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations to the extent required by law. 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. For Example: Medicare routinely does sample audits of patient records that require a copy of your record to be released to the auditors.
Abuse or Neglect: State laws may require disclosure of protected health information to a public health authority that is authorized by law to receive reports of child abuse, domestic violence or neglect. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to an agency, person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls to make repairs or replacements, or to conduct post marketing surveillance, as required. For example, an adverse reaction to a new drug would require reporting to the appropriate drug side effect registry.
Legal Actions: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal ( to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice's premises) and it is likely that a crime has occurred. Indiana Law sets specific limits on what can be released.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. For example: protected health information may be used and disclosed for eye donation purpose.
Research: We may release protected health information to reseachers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Millitary Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health info of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of the foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
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 doctor created or received your protected health information in the course of providing care to you.
Enforcement Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Your Rights to Privacy of Health Information
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise the rights.
Inspection/ Copy of Your Record: You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in our practice for as long as we maintain these records. These records include both clinical information and business activities related to your care. Under federal law, however, you may not view or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. A decision to deny access may be reviewed in some cases.
Requests to Further Restrict Disclosure: You have the right to request further restriction of your protected health information. This means you may ask us not to use or disclose parts 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 or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to who you want the restriction to apply. The practice retains the right by law to release required information for billing purposes.
Your doctor of optometry may not agree to a restriction that you may request. If your doctor 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 doctor does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by initially sending a letter to:
Brownsburg Family Eye Care, P.C.
P.O. Box 809
Brownsburg, IN 46112
Attn: Sarah
(317)852-4741
Sending this letter does not indicate that your request will be granted. If the request is agreed to in full or part, you will receive a letter granting such restrictions.
Request Alternate by Alternate Methods or Location: You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Administrator. For example, if you do not wish for information sent to an address where another individual might have access to it, you have a right to request an alternative location to receive communications.
Amending Your Records: You may have the right to have your doctor amend your protected health information. This means you may request an amendment of protected health information about you in our records for as long as we maintain this information. In certain cases, we may deny your request for an amendment. 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. Please contact our Administrator, if you have questions about amending your medical record.
For example: Your records may contain a medical history note that you had been diagnosed with chronic fatigue syndrome, but now you have bee diagnosed with multiple sclerosis and you would like the record corrected.
Right to Record of Information Disclosures: You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to personal care givers, family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that have occurred after April 14, 2003, but not more retroactive than six years. The right to receive this information is subject to certain exception, restrictions and limitations.
Right to Privacy Statement: You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
Your Recourse for Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact us for further information about the complaint process.
Brownsburg Family Eye Care, P.C.
P.O. Box 809
Brownsburg, IN 46112
Attention: Sarah
(317)852-4741
This notice was published on 2/19/2003 and all provision become effective by Federal Law on April 14, 2003. It remains in effect until modified by our practice.
