DR. SAM’S EYE CARE & SAMUEL C. GIVEEN, O.D. 
------------- Effective 4/14/03 -------------
NOTICE OF PRIVACY PRACTICES: HOW DR. SAM’S EYE CARE PROTECTS MEDICAL INFORMATION ABOUT YOU, HOW IT MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN IT

 
DR. SAM’S EYE CARE divulges health information about you to facilitate your care, obtain payment and administer and manage DR. SAM’S EYE CARE:
DR. SAM’S EYE CARE routinely obtains and divulges this information without special permission for the purposes of making your appointments, informing you of appointments, informing you of the need to make appointments, informing you of services that might benefit you, examining you, treating your vision and health problems, obtaining assistive devices for you, referring your care to other health professionals, learning about your personal health history from other professionals you have seen, coordinating your care with your family members and your friends who are helping you with your health care, determining whom to bill for services DR. SAM’S EYE CARE performs for you, preparing and sending bills and claims, collecting balances directly and through billing services, collection agencies and attorneys, performing financial and billing audits, internally assuring quality of care, making personnel decisions, participating in managed care plans, defending legal matters, making business plans and storing records outside the office.  DR. SAM’S EYE CARE may communicate with you by post card, message on an answering machine or message left with another person.  Unless you object, DR. SAM’S EYE CARE will not ask you for special permission to perform these functions.  Please inform DR. SAM’S EYE CARE in writing if these practices pose any problems for you.
 
 
DR. SAM’S EYE CARE may use or divulge information about you for reasons allowed or required by law:
It is possible that DR. SAM’S EYE CARE will divulge your health information without your permission when mandated by state or federal law, for public health reasons, for contagious disease reporting, investigation and surveillance, to communicate with the FDA regarding drugs and medical devices, to authorities regarding suspicion of abuse, neglect or domestic violence, for doctor licensing, for Medicare and Medicaid audits, regarding possible health care law violation, in response to a court or administrative agency order, to facilitate law enforcement activities, regarding a deceased’s body identification or burial, to facilitate organ or tissue donation, for health-related research, to prevent a serious threat to someone’s health or safety, for the protection of a high-ranking government official, for the facilitation of military or national intelligence activities, for evaluation of the health of foreign service members, for workers compensation claims, or to facilitate the work of our business associates and doctors who work with us, who promise to respect your privacy.  DR. SAM’S EYE CARE may make incidental disclosures that are unavoidable by-products of permitted uses and disclosures, disclose information from which has been removed any information that could identify you personally, or disclose a limited data set for public health or health care operations.
 
DR. SAM’S EYE CARE will use or divulge your health information for other reasons only with your authorization:
If you or DR. SAM’S EYE CARE wish that DR. SAM’S EYE CARE disclose your health information for any reason not listed above, DR. SAM’S EYE CARE will do so only upon your signed, written instructions in compliance with federal law.  DR. SAM’S EYE CARE can provide you with a form upon which you can provide the authorization.  You are not required to provide these instructions; they are at your discretion and you may non-retroactively revoke them by signed letter to Dr. Giveen at any time.
 
You have these rights regarding your health information:
You may ask DR. SAM’S EYE CARE, in advance, by signed letter to Dr. Giveen, to restrict the use and disclosure of your health information for any purpose excepting emergency treatment.  DR. SAM’S EYE CARE is not required to agree to this, but should DR. SAM’S EYE CARE agree, DR. SAM’S EYE CARE must honor the agreement.  You may ask DR. SAM’S EYE CARE, by signed letter to Dr. Giveen, to communicate with you confidentially via certain phone numbers, or addresses.  If the request is reasonable DR. SAM’S EYE CARE will grant it, provided you pay in advance for any extra cost incurred in so doing.  You may request, by signed letter to Dr. Giveen, copies of your health information, paid for in advance, or to view it.  Excepting certain circumstances under which DR. SAM’S EYE CARE might legally deny your request and send you a written explanation and instructions regarding how you can obtain a legal review if available, DR. SAM’S EYE CARE will arrange this for you within 30 days if the records are in the office, 60 days if they are off site, with one 30-day extension allowed if DR. SAM’S EYE CARE notifies you in advance.  You may ask DR. SAM’S EYE CARE, by signed, explanatory letter to Dr. Giveen, to amend your health information if you believe it is wrong or incomplete.  If DR. SAM’S EYE CARE agrees, DR. SAM’S EYE CARE will amend it within 60 days, with one 30-day extension allowed if DR. SAM’S EYE CARE notifies you in advance, and send the corrected information to those DR. SAM’S EYE CARE knows received the wrong or incomplete information and others you specify.  If DR. SAM’S EYE CARE does not agree, DR. SAM’S EYE CARE will include in your health information your written statement of your position along with any rebuttal DR. SAM’S EYE CARE writes and send it in permitted disclosures of your health information.  You may ask DR. SAM’S EYE CARE, by signed letter to Dr. Giveen, once per year without charge, more often for a fee, for a list of disclosures of your health information made within the last 6 years, less if you wish, excluding those made with your authorization, incidental disclosures, those required by law, some other limited disclosures, and those made for purposes of treatment, payment and administration and management of DR. SAM’S EYE CARE. DR. SAM’S EYE CARE will arrange this for you within 60 days, with one 30-day extension allowed if DR. SAM’S EYE CARE notifies you in advance.  An additional copy of this notice will be sent to you upon request.
 
DR. SAM’S EYE CARE will adhere to these provisions and you may complain:
DR. SAM’S EYE CARE may change these practices at will by making available and posting a revised notice.  DR. SAM’S EYE CARE will always apply current practices to both existing and new health information.  If you believe we have mishandled your health information, you may complain, without fear of retaliation, to DR. SAM’S EYE CARE, in person, by telephone, or by letter to Dr. Giveen, or to the U.S. Dept. of Health and Human Services, Office of Civil Rights.  If you desire further information on our privacy practices, please ask Dr. Giveen.