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Effective date: April 14,2003 NOTICE OF PRIVACY PRACTICES William R. Waldron, O.D. LC 1215V George Washington Memorial Hwy Yorktown, VA 23693 757-596-5666 fax 757-596-9755 wwaldron@erols.com Contact person: Cheryl Gallant
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. We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. this Notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we disclose your health information is for treatment, payment or healthcare operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing eyeglasses, contact lenses, eye medications and low vision aids; referring you to another doctor or clinic for eye care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose you health information for payment purposes are: asking you about your health or vision plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons we usually will not ask you for special written permission. However, we may require written authorization for the release of information related to any prescription, including but not limited to eyeglasses, contact lenses and medications.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: when a state or federal law mandates that certain health information be reported for a specific purpose; for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Federal Food and Drug Administration regarding drugs or medical devices; disclosures to governmaental authorities about victims of suspected abuse, neglect or domestic violence; uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investication of possible violations of hjealth care laws; disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; *uses or disclosures for health related research; uses and disclosures to prevent a serious htreat to health and safety; uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intellignece activities; for military purposes; or for the evaluation and health of members of the foreign service; disclosures of de-identified information; disclosures relationg to workman's compensation programs; disclosures of a "limited data set" for research, public health, or health care operations; incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; disclosures to " business associates" who perform health care operations for us and who commit to respect the privacy of your health information; disclosure where reasonably necessary to establish or collect a fee or to defend a provider or the provider's employees or staff against any accusation of wrongful conduct; also as required in the course of an investigation, audit, review or proceedings regarding a provider's conduct by a duly authorized law enforcement, licensure, accreditation, or professional review entity; disclosure necessary in connection with the care of the patient, including implementation of a hospital routine process;
disclosures in the normal course of business in accordance with accepted standards of practice within the health services setting; disclosures when the the patient has waived his right to privacy of the medical records; disclosures to the guardian ad litem in the course of a guardianship proceeding of an adult patient authorized under Artcle 1.1 of Chapter 4 of Title 37.1 Virginia Code; disclosure to the attorney and/or guardian ad litem of a minor patient who represents such minor in any judicial or administrative proceeding, provided that the court or administrative hearing officer has entered an order granting the attorney or guardian ad litem this right and such attorney or guardian ad litem presents evidence to the provider of such order; disclosure to third-party payors and their agents for the purposes of reimbursement; disclosure as is necessary to support an application for receipt of health care benefits from a governmental agency; disclosure upon the sale or change of ownership of a medical or optometric practice; disclosure of the records of a deceased or mentally incapacitated patiet to the personal representative or executor of the deceased patient or the legal guardian or committee of the incompetent or incapacitated patient or if there is no personal representative, executor, legal guardian or committee appointed, to the following persons in the following order of priorty: a spouse, an adult son or daughter, either parent, an adult brother or sister, or any other relative of the deceased patient in the order of blood relationship; Unless you object, we will also share relevant information about your care with your family or friends who are helping with your eye care.
APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that may help 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 you phone if you are not at home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written "authorization form". The content of an "authorization form" is determined by Frederal law. sometimes, we may initiate the authorization process if the uses or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process adn ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can: ask us to restrict our uses and disclosures for the purposes of treatment ( except emergency treatment), payment or healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at hte address, fax or e-mail shown at the beginning of this Notice. ask us to communicate with you in a confidential way, such as phoning you at work rather at home, by mailing health information to a different address, or by using e-mail to your personal e-mail address. We will accommodate these requests if they are reesonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or e-mail shown at the beginning of this Notice. ask to see or get photcopies of your health information. 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 15 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written expalnation, and instructions about how toget an impartial review of our denial if one is legally available. If you want to review or get phtocopies of your health information, send a written request to the office contact person at the address, fax, or e-mail shown at the beginning of ths Notice. ask us to amend your health information if you think it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to the persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and /or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. by law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request , including your reasons for the amendment, to the office contact person at hte address, fax, or e-mail shown at the beginning of this Notice. get a list of the disclosures that we have made of your health information within the past 6 years ( or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures wiht you authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. if you want more frequent lists, you will have to pay for them in advance. We will usually respond to you request within 60 days of receiving it, but by law we can have one 30 day extension if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at hte address, fax, or e-mail shown at the beginning of this Notice. get additional paper copies of this Notice of Privacy practices upon request. It does not matter whether you got one electronically or in paper form already. If you want addtional paper copies, send a written request to the office contact person at the address, fax, or e-mail shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this Notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new Notice in our office, have copies available in our office, and post it on our web site.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, yuou are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you wish to complain to us, send a written complaint to the office contact person at the address, fax, or e-mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office conact person at the address or phone number shown at hte beginning of this Notice.
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Contact Us
1215 George Washington Memorial Hwy
Suite V
Yorktown, VA 23693
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Phone: 757-596-5666
Fax: 757-596-9755
Cell Phone: 757-320-9489
Mon, Wed 9:00am - 6:00pm
Sat 9:00am - 1:00pm
Tue, Thu-Fri 9:00am - 5:00pm
Saturday and evenings we are open by appointment only. Appointments on Tuesday are from 9AM until 1 PM and Thurdays from 1 PM to 5 PM.
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