Privacy Notice
Office contact: Sandra K. Gonzalez
55 E. Washington St., Suite 647
Chicago, IL. 60602
Telephone: 312.332.0221
Fax: 312.332.0963
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 right you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason reason why we use or 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 glasses, contact lenses or eye medications and faxing them to be filled showing you low vision aids referring you to another doctor or clinic for eye care or low vision aids 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 your health information for payment purposes are: asking you about your health or vision care 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 operatons" 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 health information inside our office for these purposes without 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.
USES AND DISCLOSURE FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to 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 disclosure are:
* when a state or federal law mandates that certian health information be reported for a specific purposes
* 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 governmental authorities about victims of suspected abuse, neglect or domestic violence
* uses and disclosure for health oversight activities, such as for the licensing of doctors for audits by Medicare or Medicaid or for investigation of possible violations of health 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 burial or to organization that handle organ or tissue donations
* uses or disclosures for health related research
* uses and disclosure to prevent a serious threat to health or safety
* uses or disclosures for specialized government functions, such as for protection of the president or high ranking government officials for lawful intelligence activities for military purposes or for the evluation and health of members of the foreign services
* disclosures of deintified information
* disclosures relating to worker'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
Unless you object, we will also share relevent informaton about your care with your family or friends who are helping you with your eye care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it 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 might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not 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 form an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use 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 authorzation form, or you can use one of ours.
If we initiate the process and 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 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 use and disclosures for the purpose of treatment (except emergency treatment), payment or health care operatons. We do not have to agree to do this, this but if we agree, we must honor the restriction that you want. To ask for a restriction, send a written request to office contact person at the address or fax at the beginning of this Notice.
* ask us to communicate with you in a confidentai way, such as by phoning you at work rather that at home, by mailing health information to different address, or by using E-mail to your personal E-mail address. We will accommodate these requests if they are reasonable, 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 or fax shown at the beginning of this Notice.
* ask to see or to get photocopies 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 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopiesif we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or fax at the beginning of this Notice.
* ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 daysfrom when you ask us. We will send the corrected information to 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 we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or 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, inlcuding your reasons for amendment, to the office contact person at the address or fax at the beginning of this Notice.
* get additional paper copies of this Notice of Privacy upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address or fax 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 the law. If we change this Notice, the new privacy practices will apply to your health information that we already 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, you are free to complain to us or the U.S. Department of Health Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the sddress or fax 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 contact person at the address or phone shown at the beginning of this Notice.
55 E. Washington St., Suite 647
Chicago, IL. 60602
Telephone: 312.332.0221
Fax: 312.332.0963
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 right you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason reason why we use or 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 glasses, contact lenses or eye medications and faxing them to be filled showing you low vision aids referring you to another doctor or clinic for eye care or low vision aids 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 your health information for payment purposes are: asking you about your health or vision care 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 operatons" 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 health information inside our office for these purposes without 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.
USES AND DISCLOSURE FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to 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 disclosure are:
* when a state or federal law mandates that certian health information be reported for a specific purposes
* 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 governmental authorities about victims of suspected abuse, neglect or domestic violence
* uses and disclosure for health oversight activities, such as for the licensing of doctors for audits by Medicare or Medicaid or for investigation of possible violations of health 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 burial or to organization that handle organ or tissue donations
* uses or disclosures for health related research
* uses and disclosure to prevent a serious threat to health or safety
* uses or disclosures for specialized government functions, such as for protection of the president or high ranking government officials for lawful intelligence activities for military purposes or for the evluation and health of members of the foreign services
* disclosures of deintified information
* disclosures relating to worker'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
Unless you object, we will also share relevent informaton about your care with your family or friends who are helping you with your eye care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it 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 might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not 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 form an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use 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 authorzation form, or you can use one of ours.
If we initiate the process and 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 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 use and disclosures for the purpose of treatment (except emergency treatment), payment or health care operatons. We do not have to agree to do this, this but if we agree, we must honor the restriction that you want. To ask for a restriction, send a written request to office contact person at the address or fax at the beginning of this Notice.
* ask us to communicate with you in a confidentai way, such as by phoning you at work rather that at home, by mailing health information to different address, or by using E-mail to your personal E-mail address. We will accommodate these requests if they are reasonable, 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 or fax shown at the beginning of this Notice.
* ask to see or to get photocopies 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 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopiesif we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or fax at the beginning of this Notice.
* ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 daysfrom when you ask us. We will send the corrected information to 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 we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or 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, inlcuding your reasons for amendment, to the office contact person at the address or fax at the beginning of this Notice.
* get additional paper copies of this Notice of Privacy upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address or fax 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 the law. If we change this Notice, the new privacy practices will apply to your health information that we already 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, you are free to complain to us or the U.S. Department of Health Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the sddress or fax 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 contact person at the address or phone shown at the beginning of this Notice.