HIPAA Notice of Privacy
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.
Our goal is to take appropriate steps to attempt to safeguard any medical
or other personal information that is provided to us. The Privacy Rule
under the Health Insurance Portability and Accountability Act of 1996
("HIPAA") requires us to:
(i)Maintain the privacy of medical information provided to us
(ii)Provide notice of our legal duties and privacy practices
(iii)Abide by the terms of our Notice of Privacy Practices
WHO WILL FOLLOW THIS NOTICE
- This notice describes the
practices of our employees and staff as well as our business partners.
This notice applies to each of these individuals, entities, sites and
- In addition, these
individuals, entities, sites and locations may share medical
information with each other for treatment, payment and health care
operation purposes described in this notice.
INFORMATION COLLECTED ABOUT
In the ordinary course of receiving treatment and health care services
from us, you will be providing us with personal information such as:
- Your name, address, and phone
- Information relating to your
- Your insurance information and
- Information concerning your
doctor, nurse or other medical providers
In addition, we will gather certain medical
information about you and will create a record of the care provided to
you. Other individuals or organizations that are part of your "circle
of care"- such as the referring physician, your other doctors, your
health plan, and close friends or family members also may provide some
information to us.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
We may use and disclose personal and identifiable health information about
you for a variety of purposes. All of the types of uses and disclosures of
information are described below, but not every use or disclosure in a
category is listed.
Required Disclosures We are required to
disclose health information about you to the Secretary of Health and Human
Services, upon request, to determine our compliance with HIPAA and to you,
in accordance with your right to access and right to receive an accounting
of disclosures, as described below.
For Treatment We may use health information
about you in your treatment. For example, we may use your medical history,
such as any presence or absence of diabetes, to assess the health of your
For Payment We may use and disclose health
information about you to bill for our services and to collect payment from
you or your insurance company. For example, we may need to give payer
information about your current medical condition so that it will pay us
for the eye examinations or other services that we have furnished you. We
may also need to inform your payer of the treatment you are going to
receive in order to obtain prior approval or to determine whether the
service is covered.
For Health Care Operations We may use and
disclose information about you for the general operation of our business.
For example, we sometimes arrange for auditors or other consultants to
review our practices, evaluate our operations, and tell us how to improve
our services. Or, for example, we may use and disclose your health
information to review the quality of services provided to you.
Public Policy Uses and Disclosures There are
a number of public policy reasons why we may disclose information about
you, which are described below.
We may disclose health information about you when we are required to do so
by federal, state, or local law.
We may disclose protected health information about you in connection with
certain public health reporting activities.
We may disclose protected health information about you in connection with
certain public health reporting activities. For instance, we may disclose
such information to a public health authority authorized to collect or
receive PHI for the purpose of preventing or controlling disease, injury
or disability, or at the direction of a public health authority, to an
official of a foreign government agency that is acting in collaboration
with a public health authority. Public health authorities include state
health departments, the Center for Disease Control, the Food and Drug
Administration, the Occupational Safety and Health Administration and the
Environmental Protection Agency, to name a few.
We are also permitted to disclose protected health information to a public
health authority or other government authority authorized by law to
receive reports of child abuse or neglect. Additionally we may disclose
protected health information to a person subject to the Food and Drug
Administration's power for the following activities: to report adverse
events, product defects or problems, or biological product deviations; to
track products; to enable product recalls, repairs or replacements; or to
conduct post marketing surveillance. We may also disclose a patient's
health information to a person who may have been exposed to a communicable
disease or to an employer to conduct an evaluation relating to medical
surveillance of the workplace or to evaluate whether an individual has a
work-related illness or injury.
We may disclose a patient's health information where we reasonably believe
a patient is a victim of abuse, neglect or domestic violence and the
patient authorizes the disclosure or it is required or authorized by law.
We may disclose health information about you in connection with certain
health oversight activities of licensing and other health oversight
agencies, which are authorized by law. Health oversight activities include
audit, investigation, inspection, licensure or disciplinary actions, and
civil, criminal, or administrative proceedings or actions or any other
activity necessary for the oversight of 1) the health care system, 2)
governmental benefit programs for which health information is relevant to
determining beneficiary eligibility, 3) entities subject to governmental
regulatory programs for which health information is necessary for
determining compliance with program standards, or 4) entities subject to
civil rights laws for which health information is necessary for
We may disclose your health information as required by law, including in
response to a warrant, subpoena, or other order of a court or
administrative hearing body or to assist law enforcement identify or
locate a suspect, fugitive, material witness or missing person.
Disclosures for law enforcement purposes also permit us to make
disclosures about victims of crimes and the death of an individual, among
We may release a patient's health information (1) to a coroner or medical
examiner to identify a deceased person or determine the cause of death and
(2) to funeral directors. We also may release your health information to
organ procurement organizations, transplant centers, and eye or tissue
banks, if you are an organ donor.
We may release your health information to workers' compensation or similar
programs, which provide benefits for work-related injuries or illnesses
without regard to fault.
Health information about you also may be disclosed when necessary to
prevent a serious threat to your health and safety or the health and
safety of others.
We may use or disclose certain health information about your condition and
treatment for research purposes where an Institutional Review Board or a
similar body referred to as a Privacy Board determines that your privacy
interests will be adequately protected in the study. We may also use and
disclose your health information to prepare or analyze a research protocol
and for other research purposes.
If you are a member of the Armed Forces, we may release health information
about you for activities deemed necessary by military command authorities.
We also may release health information about foreign military personnel to
their appropriate foreign military authority.
We may disclose your protected health information for legal or
administrative proceedings that involve you. We may release such
information upon order of a court or administrative tribunal. We may also
release protected health information in the absence of such an order and
in response to a discovery or other lawful request, if efforts have been
made to notify you or secure a protective order.
If you are an inmate, we may release protected health information about
you to a correctional institution where you are incarcerated or to law
enforcement officials in certain situations such as where the information
is necessary for your treatment, health or safety, or the health or safety
Finally, we may disclose protected health information for national
security and intelligence activities and for the provision of protective
services to the President of the United States and other officials or
foreign heads of state.
Our Business Associates We sometimes work
with outside individuals and businesses that help us operate our business
successfully. We may disclose your health information to these business
associates so that they can perform the tasks that we hire them to do. Our
business associates must promise that they will respect the
confidentiality of your personal and identifiable health information.
Disclosures to Persons Assisting in Your Care or
Payment for Your Care We may disclose information to individuals
involved in your care or in the payment for your care. This includes
people and organizations that are part of your "circle of care"
- such as your spouse, your other doctors, or an aide who may be providing
services to you. We may also use and disclose health information about a
patient for disaster relief efforts and to notify persons responsible for
a patient's care about a patient's location, general condition or death.
Generally, we will obtain your verbal agreement before using or disclosing
health information in this way. However, under certain circumstances, such
as in an emergency situation, we may make these uses and disclosures
without your agreement.
Appointment Reminders We may use and
disclose medical information to contact you as a reminder that you have an
appointment or that you should schedule an appointment.
Treatment Alternatives We may use and
disclose your personal health information in order to tell you about or
recommend possible treatment options, alternatives or health-related
services that may be of interest to you.
OTHER USES AND DISCLOSURES OF PERSONAL INFORMATION
We are required to obtain written authorization from you for any other
uses and disclosures of medical information other than those described
above. If you provide us with such permission, you may revoke that
permission, in writing, at any time. If you revoke your permission, we
will no longer use or disclose personal information about you for the
reasons covered by your written authorization, except to the extent we
have already relied on your original permission.
You have the right to ask for restrictions on the ways we use and disclose
your health information for treatment, payment and health care operation
purposes. You may also request that we limit our disclosures to persons
assisting your care or payment for your care. We will consider your
request, but we are not required to accept it. You have the right to
request that you receive communications containing your protected health
information from us by alternative means or at alternative locations. For
example, you may ask that we only contact you at home or by mail.
Except under certain circumstances, you have the right to inspect and copy
medical, billing and other records used to make decisions about you. If
you ask for copies of this information, we may charge you a fee for
copying and mailing.
If you believe that information in your records is incorrect or
incomplete, you have the right to ask us to correct the existing
information or add missing information. Under certain circumstances, we
may deny your request, such as when the information is accurate and
complete. You have a right to receive a list of certain instances when we
have used or disclosed your medical information. We are not required to
include in the list uses and disclosures for your treatment, payment for
services furnished to you, our health care operations, disclosures to you,
disclosures you give us authorization to make and uses and disclosures
before April 14, 2003, among others. If you ask for this information from
us more than once every twelve months, we may charge you a fee. You have
the right to a copy of this notice in paper form. You may ask us for a
copy at any time.
To exercise any of your rights, please contact us in writing at:
Dr. David W. Gordon, O.D.
851 N. Hollywood Way
Burbank, CA 91505