|THIS NOTICE DESCRIBES
HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
State and Federal laws require us to
maintain the privacy of your health information and to inform you
about our privacy practices by providing you with this Notice.
We must follow the privacy practices as described below. This Notice
will take effect on April 14, 2003 and will remain in effect until
it is amended or replaced by us.
It is our right to change our privacy
practices provided law permits the changes. Before we make a significant
Notice will be amended to reflect the changes and we will make
the new Notice available upon request. We reserve the right to
make any changes in our privacy practices and the new terms of
our Notice effective for all health information maintained, created
and/or received by us before the date changes were made.
request a copy of our Privacy Notice at any time by contacting
our Privacy Officer, Deborah F. Valentine. Information
on contacting us can be found at the end of this Notice.
|Typical uses and disclosures
of health information
We will keep your health information
confidential, using it only for the following purposes:
Treatment: We may use your health information
to provide you with our professional services. We have established "minimum necessary
or need to know" standards that limit various staff members'
access to your health information according to their primary
job functions. Everyone on our staff is required to sign a confidentiality
Disclosure: We may disclose and/or share your healthcare information
with other health care professionals who provide treatment and/or
service to you. These professionals will have a privacy and confidentiality
policy like this one. Health information about you may also be
disclosed to your family, friends and/or other persons you choose
to involve in your care, only if you agree that we may do so.
Payment: We may use and disclose your health information to seek
payment for services we provide to you. This disclosure involves
our business office staff and may include insurance organizations
or other businesses that may become involved in the process of
mailing statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health information to
notify, or assist in the notification of a family member or anyone
responsible for your care, in case of any emergency involving
your care, your location, your general condition or death. If
at all possible we will provide you with an opportunity to object
to this use or disclosure. Under emergency conditions or if you
are incapacitated we will use our professional judgment to disclose
only that information directly relevant to your care. We will
also use our professional judgment to make reasonable inferences
of your best interest by allowing someone to pick up filled prescriptions,
x-rays or other similar forms of health information and/or supplies
unless you have advised us otherwise.
Healthcare Operations: We will use and disclose your health information
to keep our practice operable. Examples of personnel who may
have access to this information include, but are not limited
to, our medical records staff, outside health or management reviewers
and individuals performing similar activities.
Required by Law: We may use or disclose your health information
when we are required to do so by law. (Court or administrative
orders, subpoena, discovery request or other lawful process.)
We will use and disclose your information when requested by national
security, intelligence and other State and Federal officials
and/or if you are an inmate or otherwise under the custody of
Abuse or Neglect: We may disclose your health information to
appropriate authorities if we reasonably believe that you are
a possible victim of abuse, neglect, or domestic violence or
the possible victim of other crimes. This information will be
disclosed only to the extent necessary to prevent a serious threat
to your health or safety or that of others.
Public Health Responsibilities: We will disclose your health
care information to report problems with products, reactions
to medications, product recalls, disease/infection exposure and
to prevent and control disease, injury and/or disability.
Marketing Health-Related Services: We will not use your health
information for marketing purposes unless we have your written
authorization to do so.
National Security: The health information of Armed Forces personnel
may be disclosed to military authorities under certain circumstances.
If the information is required for lawful intelligence, counterintelligence
or other national security activities, we may disclose it to
authorized federal officials.
Appointment Reminders: We may use or disclose your health information
to provide you with appointment reminders, including, but not
limited to, voicemail messages, postcards or letters.
|Your privacy rights as our
Access: Upon written
request, you have the right to inspect and get copies of your health
(and that of an individual for whom you are a legal guardian.)
There will be some limited exceptions. If you wish to examine your
health information, you will need to complete and submit an appropriate
request form. Contact our Privacy Officer for a copy of the Request
Form. You may also request access by sending us a letter to the
address at the end of this Notice. Once approved, an appointment
can be made to review your records. Copies, if requested, will
be $ 0.50 for each page and the staff time charged will be
$20.00 per hour including the time required to locate and copy
your health information. If you want the copies mailed to you,
postage will also be charged. If you prefer a summary or an explanation
of your health information, we will provide it for a fee. Please
contact our Privacy Officer for a fee and/or for an explanation
of our fee structure.
Amendment: You have the right to amend your healthcare information,
if you feel it is inaccurate or incomplete. Your request must
be in writing and must include an explanation of why the information
should be amended. Under certain circumstances, your request
may be denied.
Non-routine Disclosures: You have the right to receive a list
of non-routine disclosures we have made of your health care information.
(When we make a routine disclosure of your information to a professional
for treatment and/or payment purposes, we do not keep a record
of routine disclosures: therefore these are not available.) You
have the right to a list of instances in which we, or our business
associates, disclosed information for reasons other than treatment,
payment or healthcare operations. You can request non-routine
disclosures going back 6 years starting on April 14, 2003. Information
prior to that date would not have to be released. (Example: If
you request information on May 15, 2004, the disclosure period
would start on April 14, 2003 up to May 15, 2004. Disclosures
prior to April 14, 2003 do not have to be made available.)
Restrictions: You have the right to request that we place additional
restrictions on our use or disclosure of your health information.
We do not have to agree to these additional restrictions, but
if we do, we will abide by our agreement. (Except in emergencies.)
Please contact our Privacy Officer if you want to further restrict
access to your health care information. This request must be
submitted in writing.
|Questions and complaints
You have the right to file a complaint
with us if you feel we have not complied with our Privacy Policies.
Your complaint should be directed to our Privacy Officer. If you
feel we may have violated your privacy rights, or if you disagree
with a decision we made regarding your access to your health information,
you can complain to us. In writing. Request a Complaint Form from
our Privacy Officer. We support your right to the privacy of your
information and 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.
|How to Contact Us
|Practice Name: EAST BAY EYE
Privacy Officer: Deborah F. Valentine
Telephone: 510 527-5752 ext. 20 Fax: 510 527-0184
Address: 5401 Norris Canyon Road, Suite 100, San Ramon, CA 94583