Southeast Eye Clinic: Specializing in Medical and Surgical Eye Care for Children and Adults

Southeast Eye Clinic Notice of Privacy Practices

Effective date: April 3, 2008

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. If you have any questions about this notice, please contact Sherrie Oakley, Compliance Officer.

Who will follow this notice: Any health care professional authorized to enter information into your chart. All departments of the clinic. Any member of a volunteer group that we allow to help at Southeast Eye Clinic. All Southeast Eye Clinic employees, staff and other clinic personnel. Anyone at a facility where we perform surgery. Example: We share medical information with each other for treatment, payment, or other purposes described in this notice.

Facilities: American Surgery Center, Southeast Alabama Medical Center, Flowers Hospital, Andalusia Regional Hospital

Our Pledge regarding medical information: This notice will tell you about the ways in which we may use and disclose medical information about you. This form does not constitute legal advice and is for educational purposes only. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. Southeast Eye Clinic will use all reasonable safe guards to protect your privacy.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We are committed to confidentiality, respect, and quality of care for all patients regardless of race, ethnicity, nationality, religion, sex, mental or physical disability, sexual orientation or sources of payment. We create a record of the care and services you receive at our clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by the clinic whether made by clinic staff or your personal doctor. If you have eye surgery, the facility where the surgery is performed may have different policies or notices regarding the use and disclosure of your medical information created in the surgery chart.

We are required by law to: Make sure that medical information identifying you is kept private. Give you this notice of our legal duties and privacy practices with respect to medical information about you. Follow the terms of the notice that is currently in effect.

How we may use and disclose medical information about you.

To provide treatment or services: We may disclose medical information about you to doctors, nurses, technicians, or other staff members involved in your care while you are in our clinic. We also may disclose medical information about you to people outside the clinic who may be involved in your medical care after you leave the clinic, such as family members, or others to provide services that are part of your care. Example: If you have a surgery procedure at another facility, the anesthesiologist may need to have your medical history in order to care for you while in surgery. We may send letters to your referral doctor, or your medical doctor to communicate any results that he may need in your treatment. We may discuss your medical information with a doctor, nurse, or technician, by phone. We may fax important test results to your doctor for the purpose of treatment. We may mail letters and or reports to your physician.

For payment: We may use and disclose medical information about you so that treatment and services you receive at the clinic may be billed to and payment may be collected from you, an insurance company or a third party. For Example: we may need to give your health plan information about surgery you received so that your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. However, payment for services may not be conditioned on obtaining the authorization if such conditioning is prohibited by the privacy act.

For Health care operations: We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may remove information that identifies you from this set of medical information, so that we may use it to study eye care delivery without learning whom specific patients are. We may use it in teaching personnel.

Appointment reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment or to remind you of your surgery date, time and instructions.

Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-related benefits and services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. Example: You cannot afford to buy your medicine and request assistance. We may have to share personal information about you with the pharmaceutical company in order to attempt to get assistance. Example: You may have a special need such as deafness and are scheduled for surgery. Since you will be under a sterile drape during surgery, we may need to let others involved in your care know this in order to take care of you while you are in surgery.

Individuals involved in your care or payment for your care: We may release medical information about you to a family member who is involved in your care. For Example: You may not be able to insert your own eye drops and your daughter phones to make sure she understands the instructions of how the drops are to be used.

Research: Any research or studies would not involve access to your name, address, or other information that reveals who you are.

The patient does not have to authorize release of information under these circumstances:

As required by law: We will disclose medical information about you when required to do so by federal, state, or local law.

To avert a serious threat to health or safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help to prevent the threat.

Organ transplantation: If you receive or are scheduled to receive a corneal transplant or any other procedure involving donor tissue, we may use and disclose medical information, name, address, social security number, gender, and race to the eye bank involved in preparing and matching the tissue for you. They need this information for billing also.

Military and veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits at our facility.

Workers Compensation: We may release medical information about you for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose medical information about you for public health reasons. Examples: To report child abuse or neglect. To report reactions to medications or problems with products. To notify patients of recalls of products they may be using. To prevent or control disease, injury or disability. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will make this disclosure when required by law.

Health oversight activities: We may disclose medical information to a health oversight agency for activities authorized by law. For Example: audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system and compliance.

Lawsuits and disputes: We may disclose medical information about you in response to a court or administrative order. For Example: In response to a subpoena, discovery request, or other lawful process.

Law enforcement: We may release medical information if asked to do so by law enforcement. Example: Court order, subpoena, warrant, summons; if criminal conduct while at our facility: Emergency circumstances to report a crime. If you are an inmate of a correctional institution or under custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

Nursing Home and Hospital: We may release and disclose medical information about you to the facility. This would be so that we could give orders for your medications and or treatment involved to your physician, nurses, or employees providing your care and payment of services. Normally, the nursing home will need written orders to treat the patient. We usually send these orders back with the patient after the visit. If you become an in-patient at a hospital and we provide treatment while you are there, we would also keep your health information in our clinic chart for future reference for your treatment with us upon discharge.

Your rights regarding medical information about you.

Right to inspect and obtain a copy: You have the right to inspect and obtain a copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

You must submit your request in writing to Sherrie Oakley, Compliance Officer.

102 Doctors Drive, Dothan, Al. 36301. Please allow 6 to 7 business day’s for a response. If you request a copy of the information, we charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request the denial be reviewed. Another health care professional chosen by the medical director will 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.

Right to amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the clinic. We normally keep records for a period of 6 years. After this, if there has been no patient contact we either store or destroy the records. To request an amendment, your request must be made in writing and submitted to Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, Al. 36301. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing and does not include a reason to support the request.

We may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment. Is not part of the medical information kept by or for the clinic. Is not part of the information which you would be permitted to inspect and copy, or is accurate and complete.

Right to an accounting of disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, Al. 36301. Your request must state the time period, which may not be longer than six years and may not include dates before February 26, 2003. The first list you request within a 12 month period will be free. For any additional list, we will charge for the cost of providing the list. We will notify you of the cost involved before cost are incurred.

Right to request restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example: you could ask that we not use or disclose information about your surgery.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, Al. 36301. In your request, you must tell us (1) what information you want to limit;(2) whether you want to limit our use, disclosure or both;(3) to whom you want the limits to apply, for example; disclosures to your spouse.

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 can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, Al. 36301. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper copy of this notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.SoutheastEyeClinic.com.

Changes to this notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the clinic lobby. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at our clinic for treatment or health care services as a patient, we will offer you a copy of the current notice in effect.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the clinic. To file a complaint with the clinic, contact: Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, AL. 36301. All complaints must be submitted in writing. You will not be penalized for filing a complaint. Complaints may be filed as noted above or with the Department of Health and Human Services with no retribution or retaliation.

Other uses of Medical Information: Other uses and disclosures not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. You understand that we are unable to rescind any disclosures we have already made with your permission, and that we are required to retain records of the care that we provided you for 6 years.

Right to Revoke Consent: You have the right to revoke your privacy consent should you determine any of the aforementioned rights have not been met to your satisfaction. Revocation request must be submitted in writing to Southeast Eye Clinic. Sherrie Oakley, Compliance Officer. 102 Doctors Drive, Dothan, AL 36301