PRIVACY PRACTICES OF DOMINION EYE CARE

THIS NOTICE INFORMS YOU, OUR PATIENT, HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN RECEIVE ACCESS TO THIS INFORMATION.

The Health Insurance Portability and Accountability of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally be kept confidential. This federal law gives you, the patient, new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required HIPPA, we have
prepared this explanation of how we maintain the privacy of your health information and how we may use and disclose this information.

Treatment: We may use medical information about you to provide medical treatment or services. We may disclose medical information about you to other physicians, our staff, and other hospital personnel who are involved in your medical care. We may also disclose results of tests, X-rays and related information to best provide you with the care you need.

Payment: We may use and disclose medical information about you to obtain payment from your insurance carrier or workman’s compensation carrier. We may also disclose medical information in order to obtain pre-certification for upcoming treatment or surgery. Your medical information is disclosed only to those personnel needing it to perform their job.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you are due for an appointment at our office. We use postcards and phone calls to accomplish this.

Individuals Involved in Your Care of Payment for Your Care: We may disclose information about you to a friend or relative who is involved in your medical care. We may release information to someone who helps to pay for your care. We may release information about you to an entity providing assistance during a disaster relief in order to notify your family regarding your condition and location.

Safety: We may disclose medical information about you when necessary to prevent a serious threat to your health or safety or that of the medical personnel treating you.

Health oversight: We may release information to a health oversight agency for activities authorized by law.

Lawsuits: We may release medical information about you in response to a court order. We may also release information about you in response to subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement: We may release medical information about you to a law enforcement official if asked to do so in relation to a crime investigation.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and others: We may release information about you to authorized federal officials tasked with protecting the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates: If you are an inmate at a correctional facility or under the custody of law enforcement officials, we may release medical information about you to those personnel.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care.

In order to inspect and copy medical information that may be used to make decisions about your care, you need to make the request in writing to our Manassas office, ATTN: Joann Bouchard, Practice Administrator. We must have a minimum of 72 hours to meet your request and a fee may be charged for copies, mailing and other supplies related to your request.

On rare occasions, your request may be denied. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional, chosen by us, will review your request and denial. This person will be independent of the initial review and we will abide by their decision.

Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our office. This request must be in writing with a valid reason that supports your request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment of health care operations. You also have the right to request a limit on the medical information we disclose to someone involved in your care or payment of the care.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing and allow 72 hours for it to be processed. In your request, you must detail what information you wish to restrict and to whom the limits apply.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a particular way or location. Again, you must make the request in writing to our Manassas office, ATTN: Joann Bouchard.

Changes to this Notice: We reserve the right to change this notice. We reserve the right to make the revised or change notice effective for medical information we already have about you as well as any future information.