David E. Palozej Eyecare Associates LLC
Phone 860-684-2191 Phone 860-870-4632
Fax 860-684-5346 Fax 860-870-4634
Notice of Privacy Practices
Effective date of this notice:
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
I. OUR RESPONSIBILITIES TO YOU
David E. Palozej Eyecare Associates LLC
is committed to preserving the privacy and confidentiality of your health
information that is created and maintained at our office. We are required by law to: 1. Maintain the privacy of your health
information and to provide you with Notice of our legal duties and Privacy
Practices. 2. Comply with the terms of our Notice.
We reserve the right to change our
Policy Practices at any time. You will
not automatically receive a revised Notice.
We will always post a copy of our effective Notice in our offices.
II. HOW WE MAY USE OR DISCLOSE YOUR HEALTH
INFORMATION
1.
For Treatment. We may use and disclose your
health information to provide you with
treatment and
services and to coordinate your continuing care. For example, a pharmacist will
need certain
information to fill a prescription written by one of our doctors. Also, we may
disclose your health
information to another doctor if you might be referred for additional
care.
2.
For Payment. We may use and disclose your
health information so that we can bill and receive payment for the treatment
and related services you receive. For
billing and payment purposes, we may disclose your health information to your
payment source, including an insurance or managed care
company, Medicare, Medicaid, or another third party payor. For example, we may contact your health plan
to confirm your coverage or to request prior authorization for a proposed
treatment or test.
3. For Health Care Operations. We may use and disclose your health care information
in order to
perform the
necessary administrative, educational, quality assurance, and other internal
business
functions of
our office. For example, we may disclose
your health information when we:
a. leave a message on your
answering machine
b. leave a message at your
place of employment
c.
send appointment reminders to
your home
d.
call you by name when you are in
our office
III. SPECIAL SITUATIONS
We may use and disclose your health information in
certain special situations. For these
situations, you have the right to limit these uses and disclosures as provided
for in Your Rights Regarding Your Health Information.
1.
Persons Involved In Your Care. We may disclose your health
information to a family member,
close personal friend or other
person you identify, including clergy, who is involved in your care.
We may make such disclosures when: (a) we have your verbal agreement; (b) we
make such
disclosures and
you do not object; or (c) we can infer from the circumstances that you would
not
object. These disclosures are limited to what is
relevant to the person’s involvement in your care.
IV. OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT
YOUR
Under the Privacy Regulations the law allows or
requires us to use or disclose your health information without your written
permission. Not all of these situations
will apply us; some may never happen in our office at all. These instances are as follows:
1.
As required by law. We may disclose your health
information when required by federal, state, or local law to do so.
2.
Public Health Activities. We may disclose your health
information to public health authorities that are authorized by law to receive
and collect health information. A few
examples might be contagious disease reporting, allergic reactions to medicines
or suspected child abuse.
3.
Health Oversight Activities. We may
disclose your health information to a health oversight agency for activities
authorized by law. Some of these may
include audits of records, investigations of doctors, inspections of offices,
or licensure actions.
4.
Judicial and Administrative Proceedings. We may disclose your health information in response
to a court or administrative order. For
example, if you are involved in a lawsuit we may disclose your information in
response to a subpoena, discovery request, or other lawful process.
5.
Law Enforcement. We may disclose your health
information in response to a request received from a law enforcement official
to report criminal activity or to respond to a subpoena, court order, warrant,
summons, or similar process.
6.
Coroners, Medical Examiners, or Funeral Directors. We may disclose your health information to a
coroner, medical examiner, funeral director and, if you are an organ donor, to
an organization involved in the donation of organs and tissues.
7.
Research Purposes. We may disclose your health
information for research purposes, but only if the use and disclosure of your
information has been reviewed and approved by a special Privacy Board or
Institutional Review Board.
8.
To Avert a Serious Threat to Health or Safety. We may disclose your health information when
necessary to prevent a serious threat to your health, or the health of other
individuals.
9.
Military and Veterans. We may
disclose your health information, if you are or have been a member of the armed
forces, as required by military command authorities.
10. National Security. We may disclose your health information to
authorized federal officials for purposes of intelligence, counterintelligence,
or other security activities, as authorized by law.
11. Inmates. We may disclose your health information if
you are an inmate of a correctional institution or under the custody of a law
enforcement official for certain purposes including your own health and safety
as well as that of others.
12. Workers’ Compensation. We may disclose your health information as
permitted by laws relating to workers’ compensation programs. If you have been seen or treated for a work
related illness or injury, that specific health information may be disclosed to
your employer.
13. Mental Health or HIV
Information. We may disclose your private
health information only as permitted or required by
14. Business Associates. We may disclose your health information to
our business associates, such as billing services, so that they can perform
only the job we have asked them to do.
To protect your health information, we require our business associates
to enter into a written contract that requires them to appropriately safeguard
your information.
V. YOUR WRITTEN AUTHORIZATION
IS REQUIRED FOR ALL OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION
1.
Except as described in this Notice, or as permitted by
2.
A written Authorization will specify particular uses or disclosures
that you choose to allow. The
Authorization will describe the particular health information to be used and
the purpose of the disclosure. When
possible, the written Authorization will also specify the name of the person to
whom we are disclosing the health information.
The Authorization will also contain an expiration date or event.
3.
You may revoke a written Authorization previously given by you at any
time. This also must be done in
writing. If you revoke your
Authorization, we will no longer use or disclose your health information for
the purposes specified in that Authorization except where we have already taken
action or relied on that Authorization.
VI. YOUR RIGHTS REGARDING
YOUR HEALTH INFORMATION
You have the following
rights with respect to your protected health information. The following briefly describes how you may
exercise these rights:
1.
Right To Request Restrictions. You have the right to request a restriction or
limitation on the way we use or disclose your health information for treatment,
payment or health care operations.
However, we are not required to agree to the restriction. If we do agree, that agreement must be in
writing and signed by both you and us. At that time, we will honor that
restriction except in the event of an emergency.
2.
Right To Request Confidential Communications. You have the right to request that we
communicate with you about your health matters in a certain manner or at a
certain location. For example, you can
request that we contact you only at a certain phone number. This request must be in writing and provide
specific instructions on how you wish for us to contact you.
3.
Right of Access to Personal Health Information. You have the right to inspect and, upon written
request, obtain a copy of your health information. We may deny your request to inspect or
receive copies in certain limited circumstances. If you are denied access to your health
information you have the right to request a review. All requirements, court costs and attorney’s
fees associated with a review are your responsibility.
4.
Right to Request Amendment. You have the
right to request that we amend your health information if you feel that it is
incorrect or incomplete. Your request
must be in writing and must state the reason for the requested amendment. If we agree we will amend your health
information within 30 days. We may deny
your request, but if we do we will include your
request for amendment as part of
your permanent health information.
5.
Right to an Accounting of Disclosures.
You
have the right to request an “account” of certain
disclosures of your health
information. This is a listing of
disclosures made by us, but does not
include
disclosures for treatment, payment and health care operations. The accounting will
include the disclosure date; the
name of the entity that received the information; a brief
description of the information
disclosed; and a brief statement of the purpose of the disclosure.
The first “Accounting”
provided within a 12 month period would be free.
6.
Right to Obtain a Paper Copy of
Notice. You have the right to obtain
a paper copy of this
Notice. You can request the copy of this Notice at
any time. In addition, you can obtain a
copy
of this Notice from
our website at: www.Palozejeyecare.com.
VII. COMPLAINTS
If you feel that we have violated your
Privacy Rights, you may file a complaint in writing with our office and/or with
the Office of Civil Rights in the U.S. Department of Health and Human Services
at
To file a complaint with our
office, you should contact our Privacy Officer, Pat Ducharme at
860-870-4632. All complaints must be
submitted in writing to