Privacy Policy

Notice of Privacy Practice Effective Date: August 1, 2021

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. We are required by law to maintain the privacy of your protected health information (PHI), provide you with notice of our legal duties and privacy practices regarding your PHI, to notify you if you are affected by a breach of your unsecured PHI, and to follow the terms of our notice that is currently in effect. Described below are ways we may use and disclose PHI. Except as provided in this Notice, we will use and disclose PHI only with your written authorization. You may revoke such authorization at any time by writing to our practice owner.

TREATMENT: We may use and disclose PHI for your treatment and to provide you with treatmentrelated health care services. This means that your PHI may be disclosed to doctors, nurses or other personnel, both inside and outside of our office, who are involved in your care. Results of examinations, scans, laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Additionally, we may use and disclose PHI to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.

PAYMENT: We may use and disclose PHI so that we, or others may bill and receive payment from you. For example, we may contact an insurance company, pharmacy, or another third party regarding payment for the treatment and services you received.

HEALTH CARE OPERATIONS: We may use and disclose PHI for health care operation purposes. These uses and disclosures are necessary to make sure that our patients receive quality care and to operate and manage our office. For example, we may use and disclose PHI to make sure the treatments and other services you receive are of the highest quality.

APPOINTMENT REMINDERS: We may use and disclose PHI to contact you and to remind you that you have an appointment with us. This includes phone call, text message, e-mail, and if initiated by the patient, social media messages. If you have a certain communication preference please notify us in writing.

SPECIAL SITUATIONS AS REQUIRED BY LAW: We will disclose PHI as required to do so by international, federal, state or local laws.

FAMILY & FRIENDS: We may disclose PHI to family members or close friends if we receive your verbal or written agreement or if when given an opportunity to object, you do not. We may also disclose PHI to family and friends if we can infer from the circumstances, based on our professional judgment, that you would not object. For example, we may assume you agree to disclosure when you bring your spouse, family member or friend into the exam room for discussion, evaluation or treatment.

EMERGENCY SITUATIONS OR SERIOUS A THREAT TO HEALTH AND SAFETY: We may use and disclose PHI in an emergency situation or to prevent a serious threat to your health or safety or the health and safety of the public.

MILITARY & VETERANS: If you are a member of the armed forces, we may use PHI as required by military command authorities. WORKERS’ COMPENSATION: We may release PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

PUBLIC HEALTH RISKS: We may disclose PHI for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births or deaths; report communicable or sexually transmitted diseases; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include but are not limited to investigations, audits, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

LEGAL MATTERS: If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the PHI requested.

LAW ENFORCEMENT: We may release PHI:
1) if requested by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process;
2) for the purpose of identifying or locating a suspect, fugitive, material witness or missing person, however the type of information shall be limited as required by law;
3) of a person who is a victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement;
4) about a death we may believe may be a result of criminal conduct; about criminal conduct on our premises; and
5) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

INFORMATION NOT PERSONALLY IDENTIFIABLE: We may use or disclose PHI about you in a way that does not personally identify you or reveal who you are.

OTHER USES AND DISCLOSURES: We will not use or disclose your PHI for any purpose other than those described in the previous sections without your specific authorization. We must obtain your authorization separate from any consent we may have obtained by you. If you have given us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use or disclose your PHI for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.

YOUR RIGHTS RIGHT TO INSPECT & RECEIVE COPY: You have the right to inspect and receive a copy on paper or in an electronic format of PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records. RIGHT TO AMEND: If you feel the current PHI we have is incorrect or incomplete, you may ask us to amend the information.

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. We are not required to agree to your request, except as required by law. If we agree, we will comply with your request unless PHI is needed to provide you with emergency treatment. We are required to comply with your request for restrictions on the use or disclosure of your PHI to health plans for payment or health care operations purposes when you have paid for the item or service out of pocket in full, we have been notified of the request for restriction in writing, and the disclosure is not required by law.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request, in writing, to our practice owner.

RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page underneath the title of this document.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints must be in writing. You will not be retaliated against for filing a complaint.

CONTACT INFORMATION: If you have any questions regarding this Notice, please contact: 615-384-8435. I have received, understand and consent to this practice’s Notice of Privacy Practices as written. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices. If changes to the policy do occur, this practice will provide me with a revised Notice of Privacy Practices upon my request. Privacy and Sharing of Information I authorize the clinic, Springfield Primary Eye Care Inc, and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor(s) as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.