THIS OUTLINE 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 DETAILED NOTICE OF OUR PRIVACY PRACTICES WILL BE MADE AVAILABLE TO YOU UPON REQUEST.
Use and Disclosure without Patient Acknowledgement of this Notice
In the course of your treatment at Fava and Maria Eye Associates and Valley View Surgery Center we may use and disclose protected health information for the purposes of treatment, payment or health care operations.
■ Medical Treatment – If we refer you to another doctor for further care, we may forward a copy of your medical record. Different areas of this practice may share medical information about you. We may also discuss your medical information with you to recommend possible treatment options or alternatives that may be of interest to you. Under the direct supervision of a Fava and Maria doctor, your medical information may be shared with resident physicians, physicians in training and allied health professionals involved in your care. We may disclose medical information about you to people outside the Practice who may be involved in your medical care after you leave the Practice: this may include your family members, or other personal representatives authorized by you.
■ Payment – We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company or any other third party.
■ Health Care Operations – Information from your medical record may be used in our overall compliance planning, medical review activities and arranging for legal and auditing functions.
There are certain circumstances under which we may use or disclose your medical information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law enforcement activities and for judicial and administrative proceedings.
Authorizations for Use or Disclosure
Except as outlined in the above sections, your medical information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time.
Additional Uses and Disclosures
We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits that may be of interest to you. We may leave these messages on your answering machine unless you specify otherwise. We may send reminder/reschedule post cards. These cards will not contain any information specific to your condition.
Individual Rights
You have certain rights with respect to your medical record information, as follows:
1. You may request, in writing, that we restrict the uses and disclosures of your medical records information for treatment, payment and operations or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with respect to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction. We cannot honor restrictions if we have released your health information prior to obtaining your request.
2. You have the right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location.
3. You have a right to inspect, copy and request amendment to your medical records. We will charge a reasonable fee for providing a copy of your medical records, or a summary of those records, at your request.
4. All requests for inspection, copying and/or amending information in your medical records must be made in writing and be addressed to “Privacy Officer” at our address.
5. You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your medical records information except for disclosures required for treatment, payment and health care operations, disclosures that require an Authorization, disclosures incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any 12-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same 12-month period.
6. You have the right to obtain a paper copy of this notice and to take one home with you if you wish.
7. All requests related to your rights herein must be made in writing and addressed to “Privacy Officer” at the address noted below:
Privacy Officer
Fava and Maria Eye Associates
875 Norman Drive
Lebanon, PA 17042
Our Duties
We are required by law to maintain the privacy of the protected health information in your medical records and to provide you with this Notice of its legal duties and privacy practices with respect to that information.
We are required to abide by the terms of this Notice currently in effect. We reserve the right to change the terms of this Notice at any time. All changes in this Notice will be prominently displayed and available at our office.
You may file a written complaint to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing such a complaint. Complaints may be sent to the Privacy Officer at the address listed above.