Online Forms | Deboer Eyecare in DeMotte IN

DE BOER OD., LTD

NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices (“Notice”) describes how we may use or disclose your health information and how you can get access to such information. Please read it carefully.

Your “health information,” for purposes of this Notice, is generally any information that identifies you and is created, received, maintained, or transmitted by us in the course of providing health care items or services to you. We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons we use or disclose your health information are for treatment, payment, or health care operations.

Examples include:

Treatment: Setting up appointments, examining your eyes, prescribing glasses, contact lenses, or medications, referring you to another provider, or requesting health records from other professionals.
Payment: Asking about insurance coverage, preparing and submitting claims, or collecting payment (including through third parties).
Health Care Operations: Quality assurance, billing audits, legal defense, administrative planning, or storage of records.

OTHER USES AND DISCLOSURES WITHOUT YOUR AUTHORIZATION OR CONSENT

We may disclose your health information without your authorization in certain cases permitted by law, such as:

As required by federal or state law
For public health activities (e.g., disease reporting, FDA-related activities)
For abuse, neglect, or domestic violence reporting
For health oversight (e.g., Medicare/Medicaid audits, licensing boards)
For judicial or administrative proceedings (e.g., subpoenas)
For law enforcement purposes
To medical examiners, coroners, or funeral directors
For organ and tissue donation
For health-related research
To prevent a serious threat to health or safety
For certain government functions (e.g., military, national security)
For worker’s compensation claims
As part of a limited data set
To business associates who help carry out healthcare operations
To your personal representatives (unless you object), or to individuals involved in your care or payment for care upon your death

SPECIFIC USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

Certain uses or disclosures require your express authorization, such as:

Marketing: Except for face-to-face communications or small promotional gifts, we need your authorization to use your information for marketing.
Sale of Health Information: We do not sell your information and would require your authorization before doing so.
Psychotherapy Notes: While we do not maintain these, federal law generally requires your permission for their disclosure.

YOUR RIGHTS TO AUTHORIZE OTHER USES
You may give us written authorization to use or disclose your health information for specific purposes. You may also request restrictions on disclosures to health plans for services paid in full by you or another individual.

You can revoke your authorization at any time in writing. Revocation will not affect any use or disclosure already made under your prior authorization.

YOUR INDIVIDUAL RIGHTS
You have the right:

To request restrictions on uses/disclosures for treatment, payment, or operations (though we are not required to agree)
To request confidential communications
To inspect or obtain a copy of your health records
To request an amendment to your health information if you believe it is incorrect or incomplete
To receive an accounting of disclosures (up to 6 years, not before April 14, 2003)
To designate another party to receive your health information (must be in writing)

CONTACT INFORMATION

Contact Person:
Linda Cark
Phone: (219) 937-3673
Fax: (219) 937-3905
Email: deboer@netnitco.net
Address: 609 N. Halleck, DeMotte, Indiana 46310

COMPLAINTS
If you believe your privacy rights have been violated, you may contact us or file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

CHANGES TO THIS NOTICE
We reserve the right to change our privacy practices and apply those changes to health information we already have. Any updates will be reflected in a revised Notice.

Notice Revised and Effective: September 1, 2013