THIS NOTICE DESCRIBES HOW OPTOMETRIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Here are some examples of how we might have to use or disclose your health care information:
1) Your optometrist or staff member may have to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
2) Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services.
3) Your optometrist and members of the staff may need to use your health information, examination and treatment records and your billing records for quality control purposes or other administrative purposes to efficiently and effectively run our practice.
4) Your optometrist and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. 164.520 (b)(1)(iii)(A). If you can not be reached personally at the contact numbers provided to receive an appointment reminder, a message will be left on your answering machine or with someone.
You have the right to refuse to give us authorization to contact you to provide appointment reminder, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time.
We will always respect your privacy. Other than the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:
1) We are permitted to use or disclose your health information if we are providing health care services to you based on the orders of another health care provider.
2) We are permitted to use or disclose your health information if we provide health care services to you as an inmate.
3) We are permitted to use or disclose your health information if we provide health care services to you in an emergency.
4) We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.
5) We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care.
Other than the circumstances described in the preceding five examples, any other use or disclosure of your health information will only be made with your written authorization.
From time to time our practice makes you aware of products or services that you may have an interest in purchasing. We may need to use your health information including your name, address, phone number, and you clinical records for the purpose of marketing products and services to you.
You have the right to refuse to give us authorization to contact you for marketing purposes. If you do not give us authorization it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect or copy the information that we us to market products and/or services to you at any time. Our practice and staff will receive direct or indirect remuneration from our marketing activities.
You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:
1) If we have already released your health information before we receive your request to revoke your authorization.164.508(b)(5)(i).
2) If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. If you wish to revoke your authorization please write to us at
401 West College Street
Murfreesboro, TN 37130
If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may drop your request or you are free to seek care from another health care provider.
We normally provide information about your health to you in person at the time you receive optometric services from us. We may also mail you information regarding your health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home or, if you would like the information in a different form. To help us respond to your needs, please make any request in writing.
You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing.
You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.
You have the right to request that we give you an accounting of the disclosures we have made of your health information for the last six years before the date of your request. The accounting will include all disclosures except:
1) those disclosures required for your treatment, to obtain payment for your services, or to run our practice.
2) those disclosures made to you.
3) those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved with your care.
4) those disclosures for national security or intelligence purposes.
5) those disclosures made to correctional officers or law enforcement officers.
6) those disclosures that were made prior to the effective date of the HIPAA privacy law.
We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of fee, and you will have the opportunity to withdraw or modify your request.
You may request a paper copy of this notice at any time.
We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information.
We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will apply for all of your health information in our files.
Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
You may complain to us or to the Secretary of Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be address to:
401 West College Street
Murfreesboro, TN 37130
If you would like further information about our privacy policies and practices please contact:
401 West College Street
Murfreesboro, TN 37130
Patient Name (Printed) Date
Authorized Provider Representative
Parent / Guardian (Printed)
Parent / Guardian’s Signature
401 West College Street Murfreesboro, TN 37130
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