GROSSNICKLE EYE CENTER, INC.
Notice of Privacy Practices
(Effective April 14, 2003)
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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 or need any additional information about this Notice of Privacy Practices (NPP), please contact Grossnickle Eye Center, Inc.’s (“GEC”) Contact Person at (800) 992-6975, ext. 631.
Grossnickle Eye Center, Inc.’s (“GEC”) goal is to provide quality optimal eye care at an affordable cost to our customers. An important part of this goal is to maintain the confidentiality and security of our customers' protected health information (“PHI”). We have always taken very seriously our legal requirements to protect our customers' privacy by maintaining our customers' PHI in a secure and confidential manner. We are providing this Notice of Privacy Practices (“NPP”) in accordance with federal privacy legislation, which requires that we make all of our customers aware of our practices and processes for collecting, using, disclosing, maintaining and protecting PHI, notice of your rights concerning your PHI, and our legal duties in protecting your PHI. GEC agrees to abide by the terms of its NPP then in effect.
GEC is required to give this NPP to you no later than its first delivery of services to you on or after 4-14-03. GEC is also required to make its NPP available to you at any time upon your request, and to post the NPP in a clear and conspicuous location in the waiting room of each of GEC’s offices. A copy of the NPP is also available at our website at www.gecenter.com
Definition of PHI:
“PHI” as used in this NPP means “Protected Health Information” and “Individually Identifiable Health Information”. “Protected Health Information” means any information, whether oral or recorded in any form or medium, that: is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual. “Individually Identifiable Health Information” is information that includes demographic information collected from an individual that identifies the individual or where there is a reasonable basis to believe the information can be used to identify the individual.
Required Disclosures of PHI:
GEC will disclose your PHI (without your consent or authorization) to the Secretary of the Department of Health and Human Services, when the information is required to investigate or determine whether GEC is in compliance with the federal privacy regulations. GEC will also disclose your PHI to you, so long as a valid authorization (discussed in more detail in a later section of this NPP) is received by GEC. GEC will use or disclose only the minimum necessary PHI to accomplish the purpose of the use, disclosure or request.
Permitted Uses and Disclosures of PHI:
The following describes the categories that GEC is permitted to use or disclose your PHI without obtaining your written authorization. GEC has attempted to explain what each category means and has given examples. Not every use or disclosure in a category will be listed. However, all of the ways GEC may use and disclose information without authorization will fall within one of these following:
Treatment GEC may use your PHI to provide you with medical treatment or services. GEC may disclose PHI about you to doctors, nurses, or other health care professionals who are involved in taking care of you. An example of using your PHI for treatment purposes: you are referred to GEC from your family optometrist for a cataract evaluation, the examination reveals you require cataract surgery in both eyes; a physician of GEC performs the surgery and your follow up appointments are with GEC’s health care providers; however, your glasses are made by your family optometrist after the surgery. In such an event, GEC would be allowed to share your PHI with your family optometrist.
Payment GEC may use or disclose your PHI for purposes of receiving payment for treatment and services you receive. For example, GEC may give your insurance company information about your treatment so the insurance company will pay GEC or reimburse you. GEC may also tell your insurance company about treatment you are going to receive to determine whether your insurance company will pay for it.
Health care operations includes a wide range of day-to-day activities that relate to the operations of GEC. For example, your PHI may be disclosed to GEC’s health care professionals to evaluate the performance of the health care professionals, to assess the quality of care and outcomes in your cases and similar cases, to learn how to improve GEC’s facilities and services, and, to determine how to continually improve the quality and effectiveness of the health care GEC provides.
Incidental Uses and Disclosures GEC may use and disclose PHI about you as long as GEC has complied with the minimum necessary and safeguards requirements imposed under the Privacy Standards. For example, GEC’s staff may discuss information about your care at the work station, if someone overhears that discussion, the disclosure to that person will be permitted so long as the staff discussed only the minimum necessary and GEC took appropriate steps to put safeguards in place.
Appointment Reminders GEC may use and disclose your PHI about you to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives GEC may use and disclose your PHI to tell you about or to recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services GEC may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
Fundraising Activities GEC may use and disclose PHI about you to contact you in an effort to conduct fundraising activities.
Business Associates GEC contracts with others outside of GEC’s organization to perform or assist GEC in performing functions that involve the use and disclosure of PHI. For example, GEC may contract with a billing company to do billing for GEC. The billing company will need PHI in order to perform its job. As such, GEC may disclose PHI about you to business associates of GEC so that they business associates can perform the job GEC has asked them to do. To protect your PHI, GEC will require all of its business associates to make assurances to GEC they will each appropriately safeguard your PHI.
Individuals Involved in Your Care In certain circumstances, GEC may use or disclose PHI about you to a family member, relative or close personal friend you have identified, who is involved in your medical care. In addition, GEC may disclose PHI about you to notify or assist in the notification of a family member, relative, or close personal friend who is involved in your medical care of your condition, location and status.
Disaster Relief Efforts In certain circumstances, GEC may use or disclose PHI about you to a public or private entity authorized by law to assist in disaster relief efforts for the purpose of coordinating with such entities.
Personal Representatives Except in limited circumstances, GEC must treat a personal representative of a decedent as the individual about who the PHI relates. As such, GEC may disclose PHI to your personal representative.
Adults and Emancipated Minors If a person has authority to act on behalf of an adult or an emancipated minor in making decisions related to health care, GEC must treat that person as a personal representative. As such, except in limited circumstances, GEC may disclose PHI to your personal representative as if the disclosure was being made to you.
Unemancipated Minors If, under applicable law, a parent, guardian or other person acting in loco parentis has authority to obtain access to PHI about an unemancipated minor, then GEC may disclose PHI to the person acting in loco parentis as if the disclosure was being made to the unemancipated minor.
Required by Law GEC will disclose PHI about you when it is required to do so by federal, state or local law, rule or regulation. For example, GEC may disclose information for the following purposes: for judicial and administrative proceedings pursuant to legal authority, to report information related to victims of abuse, neglect or domestic violence; and, to assist law enforcement officials in their law enforcement duties.
Public Health/Health Oversight GEC may use or disclose PHI about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.
Deceased Individuals GEC may disclose PHI to funeral directors, medical examiners and/or coroners to enable them to carry out their lawful duties.
Organ/Tissue Donation GEC may use or disclose PHI about you for cadaveric organ, eye or tissue donation purposes.
Research GEC may use or disclose PHI about you for research purposes. For example, a research project may involve comparing the health and recover of patients who received one medication to those who received another medication. All research projects are subject to a special approval process. Before GEC will use or disclose PHI about you, the project will be approved through the special approval process.
Health & Safety GEC may use or disclose your PHI to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.
Specialized Government Functions GEC may use and disclose your PHI for military and veterans activities, for national security and intelligence activities, for protective services of the President and others, and to correctional institutions and other law enforcement custodial situations.
Workers’ Compensation GEC may use and disclose PHI about you for workers’ compensation or similar programs to the extent authorized by and to the extent necessary to comply with laws regarding said programs.
FDA Reporting In the event GEC is subject to the jurisdiction of the federal Food and Drug Administration with respect to a product or activity for which GEC has a duty to make reports of quality, safety or effectiveness, GEC may use and disclose PHI about you to make any and fulfill any requirements imposed by the FDA.
Uses and Disclosures For Which Authorization is Required The following categories describe the instances in which GEC may use and disclose PHI about you after first obtaining your written authorization:
All Instances Except as Required or Permitted Except as required or permitted by the Privacy Standards, GEC may not use or disclose PHI about you without your written authorization. When GEC receives your authorization to use or disclose your PHI, GEC must make its use and disclosure consistent with such authorization. If you provide GEC authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, GEC will no longer use or disclose your PHI for the reasons covered by your authorization. However, your revocation will not be applicable to disclosures that GEC already made prior to its receipt of your written revocation.
Psychotherapy Notes GEC may not use and disclose psychotherapy notes without your authorization except: to carry out certain treatment, payment and health care operation activities; as required by law; and for health oversight activities; to coroners and medical examiners; and, to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.
Marketing GEC may not use and disclose PHI about you for marketing without your authorization, except if the communication is in the form of: face to face communication made by GEC to you; or, a promotional gift of nominal value provided by GEC.
YOUR RIGHTS REGARDING PHI ABOUT YOU:
Under the federal privacy legislation, you have the following rights concerning your PHI that GEC maintains about you:
1. Right to Request Restrictions. You have the right to request that GEC restrict or limit how it uses and discloses your PHI for treatment, payment or health care operations. GEC will consider your request, but GEC is not required to agree to your request. GEC cannot agree to limit uses and disclosures that are required by the Privacy Standards. If GEC agrees to your request, GEC will comply with your request unless the information is needed to provide you emergency treatment or in other limited circumstances. To request a restriction, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a specific description of the requested restriction, and the requested duration of the restriction. The request must also be signed and dated. Please refer to 45 C.F.R. x 164.522 for a more detailed description of your rights.
2. Request Confidential Communications. You have the right to request that GEC communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that GEC only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a specific description of the request, an identification of the alternate method of communication and/or alternate address, and the duration of the request. The request must also be signed and dated. GEC will not ask you the reason for your request and GEC will accommodate all reasonable requests. Please refer to 45 C.F.R. x 164.522 for a more detailed description of your rights.
3. Request Access to Inspect and Copy. You have the right to request access for purposes of inspecting and copying your PHI. To request access, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a description of the requested access (i.e., inspection, copying, both) and a statement as to the requested form or format of the information. The request must also be signed and dated. GEC will respond to your request within 30 days (unless the information is stored off-site, in which event GEC will respond within 60 days). If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, GEC may deny your request to inspect and copy. If you are denied access to your PHI, you may request that the denial be reviewed in certain circumstances. If you are entitled to a review, another licensed health care professional chosen by GEC will review your request and the denial. The person conducting the review will not be the person who denied your request. GEC will comply with the outcome of the review. If you request a copy of the information, GEC may charge a fee for the cost of copying, mailing and other supplies associated with your request. Please refer to 45 C.F.R. x 164.524 for a more detailed description of your rights.
4. Request Amendments. If you feel that PHI GEC has about you is incorrect or incomplete, you have the right to request that GEC amend the information. You have the right to request an amendment for as long as the information is kept by or for GEC. To request an amendment, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a specific description of the requested amendment and a description of the reason or basis for the amendment. The request must also be signed and dated. GEC will respond to your request within 60 days. If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, GEC may deny your request for an amendment. If GEC denies your request, you will be given the opportunity to submit a written statement of disagreement and/or request in writing that GEC include your request with any future disclosures of the affected information. In the event you file a written statement of disagreement, GEC will be allowed to prepare a written rebuttal. In some instances, the future disclosures of the affected information will include your request, the denial, your written statement and the rebuttal. Please refer to 45 C.F.R. x 164.526 for a more detailed description of your rights.
5. Right to Receive an Accounting of Disclosures. You have the right to request an accounting of disclosures describing certain types of disclosures GEC has made of PHI about you. To request an accounting, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, and a statement of the period of time for the accounting (which may not be longer than six (6) years and may not include dates before April 14, 2003). Your request should indicate in what form you want the accounting (for example, on paper, electronically, etc.) The request must also be signed and dated. GEC will respond to your request within 60 days. If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. The first accounting you request within a twelve (12) month period will be free of charge. For additional accountings during a twelve (12) month period, GEC may charge you for the cost of providing the accounting. GEC will notify you of the cost involved in advance and you may choose to withdraw or modify your request at that time before any costs are incurred. Please refer to 45 C.F.R. x 164.528 for a more detailed description of your rights.
6. Request Paper Copy of This NPP You have the right to a paper copy of this NPP. You may ask GEC to give you a copy of this NPP at any time. Even if you have agreed to receive this NPP electronically, you are still entitled to a paper copy of this NPP. To obtain a paper copy of this NPP, contact the Contact Person of GEC.
Complaints:
If you believe your privacy rights have been violated, you may file a complaint. To file a complaint with GEC, contact the Contact Person of GEC at (574) 269-2777, ext. 631. The Contact Person will inform you as to the formal procedure for filing a complaint with GEC and assist you in making a complaint. You will not be retaliated against for filing a complaint.
You may also file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with the Secretary, you should contact the Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC 20201; (877) 696-6775 within one hundred eighty (180) days of when you knew or should have known that the act or omission complained of occurred (this time limit can be waived by the Secretary for good cause shown). You will not be retaliated against for filing a complaint.
Changes to This Notice:
GEC reserves the right to change its privacy practices and this NPP at any time. GEC will promptly revise and distribute a revised NPP whenever required by law or when there is a material change to: the uses or disclosures that may be made by GEC; your rights with respect to your PHI; GEC’s legal duties; and/or GEC’s other privacy practices described in this NPP. GEC reserves the right to make the revised or changed privacy practices and NPP effective for PHI GEC already has about you as well as any information GEC receives in the future.
GEC will post a copy of the current NPP in the waiting room of each of GEC’s offices. The NPP will contain on the first page, in the top center section, the effective date. In addition, each time you register at GEC’s office for treatment or health care services, GEC will make available to you a copy of the current NPP then in effect. The NPP will also be available on EC’s website at www.gecenter.com.
Additional Information:
You may contact GEC's Privacy Officer at Grossnickle Eye Center, Inc., 2251 Dubois Drive, Warsaw, Indiana 46580, (574) 269-2777, if you have any questions or need any additional information.
THIS NOTICE OF PRIVACY PRACTICES WILL BE EFFECTIVE ON AND AFTER APRIL 14, 2003.
GEC is required to make a good faith effort to obtain your written acknowledgement of your receipt of this NPP. As such, please complete the attached sticker acknowledging your receipt of this NPP and give the completed sticker to a member of GEC.
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