Your health care provider and health plan is required to give you a notice that tells you how they may use and share your health information and how you can exercise your health privacy rights. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE READ IT CAREFULLY
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your protected health information (“PHI”) is used. HIPAA provides penalties for covered entities that misuse protected health information.
As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation.
Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would include referring you to a retina specialist or having a medical student observe your exam.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards.
The practice may also disclose your PHI for law enforcement and other legitimate reasons although we shall do our best to assure its continued confidentiality to the extent possible.
We may also create and distribute de-identified health information by removing all reference to individually identifiable information.
We may contact you unless stated otherwise, by phone, in writing or with an open faced postcard, to provide appointment reminders, appointment recalls, missed appointment information or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to “opt out” with respect to receiving any of these communications from us, including information regarding fundraising.
The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:
Most uses and disclosure of psychotherapy notes;
Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
Disclosures that constitute a sale of PHI under HIPAA; and
Other uses and disclosures not described in this notice.
You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You may have the following rights with respect to your PHI.
The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of PHI by alterative means or at alternative locations.
The right to inspect and copy your PHI.
The right to amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from us upon request.
The right to be advised if you’re unprotected PHI is intentionally or unintentionally disclosed.
If you have paid for services “out of pocket”, in full, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.
We are required by law to maintain the privacy of your PHI and to provide you the notice of our legal duties and our privacy practice with respect to PHI.
This notice if effective as of September 9, 2013 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practice from our office.
You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with office and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.
Feel free to contact the Practice Privacy Officer for more information, in person or in writing. To exercise any of your rights in writing, please contact us at:
Fort Worth Eye Associates
Nora Rios, Practice Privacy Officer
5000 Collinwood Ave
Fort Worth, TX 76107
We are committed to maintaining your privacy.
Nondiscrimination Statement: Discrimination is Against the Law
Fort Worth Eye Associates complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Fort Worth Eye Associates does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Fort Worth Eye Associates:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: Qualified Interpreters
Information written in other languages
If you need these services, contact Jennifer Garland, Civil Rights Coordinator.
If you believe that Fort Worth Eye Associates has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Jennifer Garland, Office Manager, Civil Rights Coordinator
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Jennifer Garland, Office Manager, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.