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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.
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OUR LEGAL DUTY
We are required by applicable federal and state law
to maintain the privacy of your health information.
We are also required to give you this Notice about
our privacy practices, our legal duties, and your
rights concerning your health information. We must
follow the privacy practices that are described in
this Notice while it is in effect. This Notice takes
effect October 1, 2005, and will remain in effect
until we replace it.
We reserve the right to change our privacy practices
and the terms of this Notice at any time, provided
such changes are permitted by applicable law. We reserve
the right to make the changes in our privacy practices
and the new terms of our Notice effective for all
health information that we maintain, including health
information we created or received before we made
the changes. In the event we make a material change
in our privacy practices, we will change this Notice
and provide it to you at your next visit or it can
be viewed in the store or on our Web site.
You may request a copy of our Notice at any time.
For more information about our privacy practices,
or for additional copies of this Notice, please contact
us using the information listed at the end of this
Notice.
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USES AND DISCLOSURES OF HEALTH INFORMATION
We use health information about you for treatment,
to obtain payment for treatment, for administrative
purposes, and to evaluate the quality of care and
service that you receive. Your health information
is contained in a medical or optical dispensary record
that is the physical property of Linsey Eyecare.
How We May Use or Disclose Your Health Information
For Treatment. We may use or disclose
your health information to an optometrist, ophthalmologist,
optician or other healthcare providers providing treatment
to you for:
• the provision, coordination,
or management of health care and related services
by health care providers;
• consultation between health
care providers relating to a patient/customer;
• the referral of a patient
for health care from one health care provider to another;
or
• appointment reminders and
recall information.
For Payment. We may use and disclose
your health information to others for purposes of
processing and receiving payment for treatment and
services provided to you. This may include:
• billing and collection
activities and related data processing;
• actions by a health plan
or insurer to determine or fulfill its responsibilities
for coverage and provision of benefits under its health
plan or insurance agreement, determinations of eligibility
or coverage, adjudication or subrogation of health
benefit claims;
• medical necessity and appropriateness
of care reviews, utilization review activities; and
• disclosure to consumer
reporting agencies of information relating to collection
of payments.
For Health Care Operations. We may
use and disclose health information about you for
operational purposes. For example, your health information
may be disclosed to:
• evaluate the performance
of our associates;
• assess the quality of service,
product and care in your case and similar cases;
• learn how to improve our
facilities and services;
• conduct training programs
or credentialing activities; and
• determine how to continually
improve the quality and effectiveness of the products,
service and care we provide.
Appointments, Treatment and Quality Assurance.
We may use your information to provide appointment
reminders or recall notices (such as voicemail messages,
postcards or letters) or information about treatment
alternatives or other health-related benefits, products
and services that may be of interest to you. We may
also contact you to conduct our own surveys about
the quality of the products and services we provide.
To You, Your Family and Friends.
We must disclose your health information to you, as
described in the Your Health Information Rights section
of this Notice. We may disclose your health information
to a family member, friend or other person to the
extent necessary to help with your healthcare or with
payment for your healthcare, but only if you agree
that we may do so or, if you are not able to agree,
if it is necessary in our professional judgment.
Persons Involved in Care. We may
use or disclose health information to notify, or assist
in the notification of (including identifying or locating)
a family member, your personal representative or another
person responsible for your care, of your location
or your general condition. If you are present, then
prior to use or disclosure of your health information,
we will provide you with an opportunity to object
to such uses or disclosures. In the event of your
incapacity or emergency circumstances, we will disclose
health information based on a determination using
our professional judgment disclosing only health information
that is directly relevant to the person's involvement
in your healthcare. We will also use our professional
judgment and our experience with common practice to
make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions,
medical supplies, photos, or other similar forms of
health information.
Required by Law. We may use and disclose
information about you as required by law. For example,
we 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;
• to assist law enforcement
officials in their law enforcement duties; or
• to assist public health
officials avert a serious threat to the health or
safety of you or any other person.
Decedents. Health Information may
be disclosed to funeral directors or coroners to enable
them to carry out their lawful duties.
Organ/Tissue Donation. Your health
information may be used or disclosed for cadaveric
organ, eye or tissue donation purposes.
Research. We may use your health
information for research purposes when an institutional
review board or privacy board that has reviewed the
research proposal and established protocols to ensure
the privacy of your health information has approved
the research.
Government Functions. Specialized government
functions such as protection of public officials or
reporting to various branches of the armed services
that may require use or disclosure of your health
information.
Worker Compensation. Your health
information may be used or disclosed in order to comply
with laws and regulations related to Worker Compensation.
Marketing Health Products or Services. We
will not use your health information for marketing
communications without your prior written authorization.
We may, however, provide you with information regarding
products or services that we offer related to your
health care needs. We will never sell your health
information without your prior authorization.
Your Authorization. In addition to
our use of your health information for treatment,
payment or healthcare operations, you may give us
written authorization to use your health information
or to disclose it to anyone for any purpose. If you
give us an authorization, you may revoke it in writing
at any time. Your revocation will not affect any use
or disclosures permitted by your authorization while
it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information
for any reason except those described in this Notice.
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YOUR HEALTH INFORMATION RIGHTS
Access: You have the right to review
or get copies of your health information, with limited
exceptions. You may request that we provide copies
in a format other than photocopies. We will use the
format you request unless we cannot practicably do
so. You may be asked to make a request in writing
to obtain access to your health information. You may
obtain a form to request access by using the contact
information listed at the end of this Notice. We will
charge you a reasonable cost-based fee for expenses
such as copies and staff time. You may also request
access by sending us a letter to the address at the
end of this Notice setting forth the specific information
to which you desire access. If you request an alternative
format, provided that it is practicable for us to
produce the information in such format, we will charge
a cost-based fee for providing your health information
in that format. If you prefer, we will prepare a summary
or an explanation of your health information for a
fee. Contact us using the information listed at the
end of this Notice for a full explanation of our fee
structure.
Disclosure Accounting: You have the
right to receive a list of instances in which we or
our business associates disclosed your health information
for purposes other than treatment, payment, healthcare
operations, where you have provided an authorization
and certain other activities, for the last 6 years,
but not for disclosures made prior to April 14, 2003.
If you request this accounting more than once in a
12-month period, we may charge you a reasonable, cost-based
fee for responding to these additional requests.
Restriction: You have the right to
request that we place additional restrictions on our
use or disclosure of your health information. We are
not required to agree to these additional restrictions,
but if we do, we will abide by our agreement (except
in an emergency).
Alternative Communication: You have
the right to request in writing that we communicate
with you about your health information by alternative
means or to alternative locations. Your request must
specify the alternative means or location, and provide
satisfactory explanation how payments will be handled
under the alternative means or location you request.
Amendment: You have the right to
request that we amend your health information. Your
request must be in writing, and it must explain why
the information should be amended. We may deny your
request under certain circumstances. You may obtain
a form to request an amendment to your health information
by using the contact information listed at the end
of this Notice.
Electronic Notice: If you receive this Notice
on our Web site or by electronic mail (e-mail), you
are entitled to receive this Notice in written form.
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QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices
or have questions or concerns, please contact us.
If you are concerned that we may have violated your
privacy rights, or you disagree with a decision we
made about access to your health information or in
response to a request you made to amend or restrict
the use or disclosure of your health information or
to have us communicate with you by alternative means
or at alternative locations, you may complain to us
using the contact information listed at the end of
this Notice. You also may submit a written complaint
to the U.S. Department of Health and Human Services.
We will provide you with the address to file your
complaint with the U.S. Department of Health and Human
Services upon request.
We support your right to the privacy of your health
information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S.
Department of Health and Human Services.
Contact Information
If you have any questions or complaints, please contact:
Linsey Eyecare
Port Richey, FL
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Phone (727) 844-3400 • Fax (727) 848-6641 • 8936 US
HWY 19 North, Port Richey, FL • Just south of Gulfview Mall
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