Privacy Page

Notice of Privacy Practices

From the Office of R. Jody Brinegar, O.D.

4001 E. 3rd St. Suite #8
Bloomington, In 47401

Effective Date: 3/18/03
Last Revised: 4/10/03

This notice is provided to inform you of the ways in which we may use and share your health information. It also details your rights to this information and certain duties we may have regarding the use and disclosure of your medical information. This notice applies to all of the records of your care generated by our practice, whether made by our practice or an associated facility. Our Practice provides this notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

OUR PROMISE REGARDING YOUR PROTECTED HEALTH INFORMATION

The privacy of your health information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create paper and electronic medical records concerning your health, our care for you, and the services and/or items that we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.

OUR LEGAL DUTY

Law requires that we:

Keep your protected health information private.
Provide you with a copy of this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
Follow the terms of the Notice that is currently in effect.

We have the right to:

Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Before we make any important changes in our privacy practices, we will change this notice and make the new notice available upon request, as well as posting a copy in public view at our office.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION

The following describes how we may use and disclose health information. We will not use your health information for any purpose not listed below without your specific written authorization. Any specific written authorization you provide may be revoked at any time by your written request.

Medical Treatment. We may use health information about you to provide you with medical treatment or services. In turn, we may disclose medical information about you to doctors, nurses, technicians, medical students, hospital personnel, pharmacists, or other health care providers who are involved in your care.
Payment. We may use and disclose your health information for payment purposes. This includes, but is not limited to, insurance, billing, accounting, and collections.
Office Operations. We may use and disclose your health information for our health care operations. This might include measuring and improving quality of care, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses, and credentials we need to serve you. This also includes the use of personal information to contact you for appointments and patient recall reminders. This contact may be by phone, in writing, or by e-mail, which could potentially be received or intercepted by others. We may also share information with business associates that have signed a business associate contract with us. Examples of such associates include optical labs and lens/eyewear manufacturers.
Research. We may disclose medical information for research purposes in limited circumstances where the research is subject to a review process and follows established protocols to ensure the privacy of health information. We will obtain an Authorization from you before using and disclosing your individually identifiable health information unless the authorization requirement has been waived.
Emergency Situations. In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status, and location.
Public Health Issues. Law or public policy may require that we disclose your health information to public health or legal authorities for reasons including, but not limited to:
- Prevention and control of disease, injury, or disability, including child abuse and neglect.
- Reporting births and deaths.
- Reporting reactions to medications or problems with products.
- Notification of product recalls.
- Notification of exposure to contaminants or communicable disease.
- Notification to the appropriate authorities in cases of suspected abuse, neglect or domestic violence, when required or authorized by law.

Law Enforcement, Court Orders, and Judicial and Administrative Proceedings. We may release health information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, discovery request, warrant, summons or similar process.
- To identify or locate a suspect, fugitive, material witness, or missing person.
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement.
- About an injury or death we believe may be the result of criminal conduct.
- About criminal conduct at our office.
- In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
- Concerning an inmate or person in lawful custody of a law enforcement agency or correctional facility.
- In order to defend ourselves, or any member of our Practice, in an actual or threatened action.

When allowed by law, we shall attempt to notify you of such requests so that you may obtain an order protecting the information requested, if you so desire.

Specialized Government Functions. Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Worker's Compensation. We may disclose health information when authorized and necessary to comply with laws relating to worker's compensation or other similar programs
Coroners, Medical Examiners, and Funeral Directors. We may share personal medical information with a coroner, medical examiner, or funeral director in the event of your passing. If you are an organ donor, we may we may release health information to organizations that oversee organ procurement or transplantation.

YOUR INDIVIDUAL RIGHTS

You have a right to:

Look at or get copies of your health information. You may request that we provide copies in a format other than photocopies. We will use the format that you request, unless it is not practical for us to do so. You must make your request in writing. You may ask the receptionist for the form necessary to request access. There may be charges for copying and postage if you want copies mailed to you. Ask the receptionist about our fee structure.
An Accounting of Disclosures. You may receive a list of times that our practice, or our business associates, shared your health information for purposes other that treatment, payment, and healthcare operations and other specified exceptions. The request cannot exceed the time period of six years prior to the submission of the written request, and cannot include dates prior to the implementation date of the HIPAA Privacy Regulations, April 14th, 2003.
Request that we place additional restrictions on our use and 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 the case of an emergency). This request must be made in writing to our Privacy Officer.
Request that we communicate with you about your medical information by different means, or to different locations. This request must be made in writing to our Privacy Officer.
Request that we amend your medical information. This request must be made in writing to our Privacy Officer. We may deny your request if we did not create the information you want changed, if it is not part of the medical information kept by or for our Practice, if the information is inaccurate or incomplete, or for other certain reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information that you want changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the change in any future sharing of that information.
To receive a paper copy of our Notice of Privacy Practices. You may request a copy of this notice at any time.

QUESTIONS AND COMPLAINTS

If you have any questions about this notice, please ask the receptionist for help, or ask to speak to our Privacy Officer. If you think your privacy rights have been violated, you may submit a complaint to our office via the Privacy Officer. You may also 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 if necessary. All complaints must be submitted in writing, and all complaints will be investigated, with no repercussion to you. You will not be penalized for filing a complaint.