NOTICE OF PRIVACY PRACTICES
For Roholt Vision Institute, Inc.
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.
Dear Patient: We understand that your health information is personal to you, and we are committed to protecting the information about you. We rely on you to give us complete and accurate information about your condition, symptoms and health history to diagnose and treat you. We appreciate how you trust us with this information. This Notice of Privacy Practices (or “Notice”) describes how we will use and disclose protected information and data that we receive or create related to your health care as well as your rights regarding your health information. We are required by law to maintain the privacy of your health information, and to give you this Notice describing our legal duties and privacy practices.
If you have any questions about our Privacy Practices, including your rights and ability to voice your concerns, please call our Privacy Officer at 330-305-2200.
How We May Use and Disclose Health Information About You
The most common reason why we use or disclose your health information is for treatment, payment or health care operations.
Treatment – We will use and disclose your health information while providing, coordinating or managing your health care. For example, information obtained by the physician or from a member of our staff during the course of your exam will be documented in your record along with the findings. This documentation may be forwarded to other healthcare providers, hospitals, or nursing homes that are involved in treating you. Information obtained may also be disclosed to your pharmacy or optical lab to fill your prescription or your contact lens or glass prescription. Roholt Vision Institute, Inc. may request your medical information from other health care providers previously seen to assist in your care.
Our records may contain information we receive from other sources, such as your optometrist or hospital (if you have been a patient or had tests performed). If another doctor or provider (hospital or nursing home) treating you asks for your office record, our policy is to send the entire record. We believe that is in the best interests of patient care and treatment. Please let us know if you have a concern about our sending the entire record.
Payment – We will use and disclose your medical information to obtain or provide compensation or reimbursement for providing your health care. For example, a bill will be sent to you if you have an outstanding balance, your health plan, or to an outside collection agency if your account becomes delinquent. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis and procedures. As another example, we may disclose information about you to your health plan so that the health plan may determine your eligibility for payment of certain benefits.
Health Care Operations – We will use and disclose your health information to deal with certain administrative aspects of your health care, and to efficiently manage our business. For example, financial or billing audits, internal quality assurance, surgery outcomes, participation in managed care plans, defense of legal matters, business planning, and outside storage of our records.
Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associates so they can perform the job we’ve asked them to do. However, we require the business associates to take precautions to protect your health information.
Research: Consistent with applicable law we may disclose 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 health information.
Appointment Reminders: We will call or write to remind you of scheduled appointments, missed appointments, or that it is time to make your appointment. We may also call or write to notify you of other treatments or services available at our office that might benefit you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
Marketing/Internet: Protected health information such as name, address, phone, & date of birth sent to us via the internet will be added to Roholt Vision Institute. Inc.’s marketing data base. A mailing will be sent initially providing you with information regarding the practice. Future mailings may occur to inform you of new treatments or services or special promotions.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events, product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, including child abuse and neglect.
Funeral Director, Coroner, and Medical Examiner: Consistent with applicable law we may disclose health information to funeral directors, coroners, and medical examiners to help them carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant (this includes eye banks).
Health Oversight: In order to oversee the health care system, government benefits programs, entities subject to governmental regulation and civil rights laws for which health information is necessary to determine compliance, we may disclose your health information for oversight activities authorized by law, such as audits and civil, administrative, or criminal investigations.
Law Enforcement: Under certain circumstances, we may disclose your health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
We may not make any other use or disclosure of your personal health information without your written authorization. Once given, you may revoke the authorization in writing to Roholt Vision Institute, Inc. Attention: Privacy Officer. Understandably, we are unable to take back any disclosure we have already made with your permission.
You have many rights concerning the confidentiality of your health information. You have the right:
- To request restrictions on the health information we may use and disclose for treatment, payment, and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to the Privacy Officer at Roholt Vision Institute, Inc.
- To receive confidential communications of health information about you in a certain manner or at a certain location. For instance, you may request that we only contact you at work or by mail. To make such a request, send a written request of how or where you wish to be contacted to the Privacy Officer at Roholt Vision Institute, Inc.
- To inspect or copy your health information. You must submit your request in writing to the Privacy Officer at Roholt Vision Institute, Inc. 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 your request. You may be charged a fee for the cost of copying and mailing in advance. If you are denied access to your health information, we will send you a written explanation. You may request that the denial be reviewed. Another licensed health care professional will then review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to the Privacy Officer at Roholt Vision Institute, Inc. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if:
- The information was not created by us, unless the person that created the information
is no longer available to make the amendment,
- The information is not part of the health information kept by or for us,
- Is not part of the information you would be permitted to inspect or copy, or
- Is accurate and complete
- The information was not created by us, unless the person that created the information
- To receive an accounting of disclosures of your health information. You must submit a request in writing to the Privacy Officer at Roholt Vision Institute, Inc. Not all health information is subject to this request. Your request must state a time period, no longer than 6 years and may not include dates before April 14, 2003. Your request must state how you would like to receive the report. The first accounting you request within a 12-month period is free. For additional requests, there may be a charge. We will notify you of this cost and you may choose to withdraw or modify your request before charges are incurred.To receive additional copies of this Notice upon request. If you would like an additional copy, send your request to the Privacy Officer at Roholt Vision Institute, Inc.
If you believe that your privacy rights have been violated, a complaint may be made to Roholt Vision Institute, Inc. Attention: Privacy Officer at 5890 Mayfair Rd., N. Canton, OH 44720. You may also submit a complaint to the Secretary of the Department of Health and Human Services. Roholt Vision Institute, Inc. will not retaliate against you for filing a complaint.
Changes to This Notice
We reserve the right to change our privacy practices and to apply the revised practices to the health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, you will be notified of such change. We will post the new notice in our office, have copies available, and post it on our Web site.
Notice effective date: April 14, 2003