Effective date of notice: 4-14-03
NOTICE OF PRIVACY PRACTICES
Colorado Eye Center-Optometry, L.L.C.
10001 N. Washington, Thornton, CO
80229 303-451-8075
4 Garden Center, Broomfield, CO 80020
303-469-1941
1371 E. Hecla Dr., Suite C, Louisville, CO 80027 303-666-7226
12450 York St, Thornton, CO 80241
303-452-2020
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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.
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We respect our legal obligation to keep
health information that identifies you
private. We are obligated by law to give
you notice of our privacy practices. This
Notice describes how we protect your
health information and what rights you
have regarding it.
TREATMENT, PAYMENT, AND HEALTH
CARE OPERATIONS
The most common reason why we use or
disclose your health information is for
treatment, payment or health care
operations. Examples of how we use or
disclose information for treatment
purposes are: setting up an appointment
for you; testing or examining your eyes;
prescribing glasses, contact lenses, or
eye medications and faxing them to be
filled; showing you low vision aids;
referring you to another doctor or clinic for
eye care or low vision aids or services; or
getting copies of your health information
from another professional that you may
have seen before us. Examples of how
we use or disclose your health information
for payment purposes are: asking you
about your health or vision care plans, or
other sources of payment; preparing and
sending bills or claims; and collecting
unpaid amounts (either ourselves or
through a collection agency or attorney).
?Health care operations? mean those
administrative and managerial functions
that we have to do in order to run our office.
Examples of how we use or disclose your
health information for health care
operations are: financial or billing audits;
internal quality assurance; personnel
decisions; participation in managed care
plans; defense of legal matters; business
planning; and outside storage of our
records.
We routinely use your health information
inside our office for these purposes
without any special permission. If we
need to disclose your health information
outside of our office for these reasons, we
usually will not ask you for special written
permission.
USES AND DISCLOSURES FOR OTHER
REASONS WITHOUT PERMISSION
\tIn some limited situations, the law allows
or requires us to use or disclose your
health information without your
permission. Not all of these situations will
apply to us; some may never come up at
our office at all. Such uses or disclosures
are:
\tWhen a state or federal law mandates
that certain health information be reported
for a specific purpose;
\tFor public health purposes, such as
contagious disease reporting,
investigation or surveillance; and notices
to and from the federal Food and Drug
Administration regarding drugs or medical
devices;
\tDisclosures to governmental authorities
about victims of suspected abuse, neglect
or domestic violence;
\tUses and disclosures for health
oversight activities, such as for the
licensing of doctors; for audits by Medicare
or Medicaid; or for investigation of possible
violations of health care laws;
\tDisclosures for judicial and
administrative proceedings, such as in
response to subpoenas or orders of
courts or administrative agencies;
\tDisclosures for law enforcement
purposes, such as to provide information
about someone who is or is suspected to
be a victim of a crime; to provide
information about a crime at our office; or
to report a crime that happened
somewhere else;
\tDisclosure to a medical examiner to
identify a dead person or to determine the
cause of death; or to funeral directors to
aid in burial; or to organizations that
handle organ or tissue donations;
\tUses or disclosures for health related research:
\tUses and disclosures to prevent a
serious threat to health or safety;
\tUses or disclosures for specialized
government functions, such as for the
protection of the president or high ranking
government officials; for lawful national
intelligence activities; for military
purposes; or for the evaluation and health
of members of the foreign service;
\tDisclosures of de-identified information;
\tDisclosures relating to worker?s
compensation programs;
Disclosures of a ?limited data set? for research, public health, or health care
operations;
Incidental disclosures that are an
unavoidable by-product of permitted uses
or disclosures;
Disclosures to ?business associates?
who perform health care operations for us
and who commit to respect the privacy of
your health information;
[Specify other uses and disclosures
affected by state law].
\tUnless you object, we will also share
relevant information about your care with
your family or friends who are helping you
with your eye care.
APPOINTMENT REMINDERS
We may call or write to remind you of
scheduled appointments, or that it is time
to make a routine appointment. We may
also call or write to notify you of other
treatments or services available at our
office that might help you. Unless you tell
us otherwise, we will mail you an
appointment reminder on a post card,
and/or leave you a reminder message on
your home answering machine or with
someone who answers your phone if you
are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or
disclosures of your health information
unless you sign a written ?authorization
form.? The content of an ?authorization
form? is determined by federal law.
Sometimes, we may initiate the
authorization process if the use or
disclosure is our idea. Sometimes, you
may initiate the process if it?s your idea for
us to send your information to someone
else. Typically, in this situation you will
give us a properly completed authorization
form, or you can use one of ours.
If we initiate the process and ask you to
sign an authorization form, you do not have
to sign it. If you do not sign the
authorization, we cannot make the use or
disclosure. If you do sign one, you may
revoke it at any time unless we have
already acted in reliance upon it.
Revocations must be in writing. Send
them to the office contact person named at
the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR
HEALTH INFORMATION
The law gives you many rights regarding
your health information. You can:
\tAsk us to restrict our uses and
disclosures for purposes of treatment
(except emergency treatment), payment or
health care operations. We do not have to
agree to do this, but if we agree, we must
honor the restrictions that you want. To
ask for a restriction, send a written request
to the office contact person at the address
or fax shown at the beginning of this
Notice.
\tAsk us to communicate with you in a
confidential way, such as by phoning you
at work rather than at home, by mailing
health information to a different address,
or by using E mail to your personal E Mail
address. We will accommodate these
requests if they are reasonable, and if you
pay us for any extra cost. If you want to
ask for confidential communications, send
a written request to the office contact
person at the address or fax shown at the
beginning of this Notice.
\tAsk to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse
to permit access or copying. For the most
part, however, you will be able to review or
have a copy of your health information
within 30 days of asking us (or sixty days if
the information is stored off-site). You may
have to pay for photocopies in advance. If
we deny your request, we will send you a
written explanation, and instructions about
how to get an impartial review of our denial
if one is legally available. By law, we can
have one 30 day extension of the time for
us to give you access or photocopies if we
send you a written notice of the extension.
If you want to review or get photocopies of
your health information, send a written
request to the office contact person at the
address or fax shown at the beginning of
this Notice.
\tAsk us to amend your health information if you think that it is incorrect or incomplete.
If we agree, we will amend the information
within 60 days from when you ask us. We
will send the corrected information to
persons who we know got the wrong
information, and others that you specify. If
we do not agree, you can write a statement
of your position, and we will include it with
your health information along with any
rebuttal statement that we may write.
Once your statement of position and/or our
rebuttal is included in your health
information, we will send it along
whenever we make a permitted disclosure
of your health information. By law, we can
have one 30 day extension of time to
consider a request for amendment if we
notify you in writing of the extension. If you
want to ask us to amend your health
information, send a written request,
including your reasons for the
amendment, to the office contact person at
the address or fax shown at the beginning
of this Notice.
\tGet a list of the disclosures that we have made of your health information within the past six years (or shorter period if you
want). By law, the list will not include:
disclosures for purposes of treatment,
payment or health care operations;
disclosures with your authorization;
incidental disclosures; disclosures
required by law; and some other limited
disclosures. You are entitled to one such
list per year without charge. If you want
more frequent lists, you will have to pay for
them in advance. We will usually respond
to your request within 60 days of receiving
it, but by law we can have one 30 day
extension of time if we notify you of the
extension in writing. If you want a list,
send a written request to the office contact
person at the address or fax shown at the
beginning of this Notice.
\tGet additional paper copies of this
Notice of Privacy Practices upon request.
It does not matter whether you got one
electronically or in paper form already. If
you want additional paper copies, send a
written request to the office contact person
at the address or fax shown at the
beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this
Notice of Privacy Practices until we choose
to change it. We reserve the right to
change this notice at any time as allowed
by law. If we change this Notice, the new
privacy practices will apply to your health
information that we already have as well
as to such information that we may
generate in the future. If we change our
Notice of Privacy Practices, we will post the
new notice in our office, have copies
available in our office, and post it on our
Web site.
COMPLAINTS
If you think that we have not properly
respected the privacy of your health
information, you are free to complain to us
or the U.S. Department of Health and
Human Services, Office for Civil Rights.
We will not retaliate against you if you
make a complaint. If you want to complain
to us, send a written complaint to the office
contact person at the address, fax or E
mail shown at the beginning of this Notice.
If you prefer, you can discuss your
complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our
privacy practices, call or visit the office
contact person at the address or phone
number shown at the beginning of this
Notice.