Privacy Notice
Notice of Privacy Practices
Effective date of notice: April 01, 2004
Office Address: 3301 E. 12th St. #109 Oakland, CA 94601
Phone # (510) 533-6567
Fax # (510) 533-6566
This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. Please review it carefully.
General Rule
We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices. Generally, we can only use your health information in our office or disclose it outside of our office, without your written permission, for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.
Uses or Disclosures of Health Information
Examples of how we use information for treatment purposes:
We may disclose your health information outside of our office for treatment purposes, for example:
If we refer you to another doctor or clinic for eye care or low vision aids or services
If we send a prescription for glasses or contacts to another professional to be filled
When we provide a prescription for medication to a pharmacist
When we phone you regarding issues of your glasses or contact lenses
Sometimes we may ask for copies of your health information from another professional that you may have seen before.
We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:
We may use and disclose your health information for healthcare operations in a number of ways. Healthcare operations means those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.
Appointment Reminders
We may call to remind you of schedule appointments. We may also call to notify you of other treatments or services available at our office that might help you. We may also contact you to conduct our own surveys about the quality of the products and services we provide.
To You, Your Family and Friends
We must disclose your health information to you, as described in the Your Health Information Rights section of the Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.
Persons Involved in Care
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location or your general condition. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person?s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, photos, or other similar forms of health information.
Required by law
We may use and disclose information about you as required by law. For example, we may disclose information for the following purposes:
Decedents
Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
Organ/Tissue Donation
Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.
Research
We may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.
Government Functions
Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
Workers Compensation
Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation
Marketing Health Products or Services
We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.
Your Authorization
In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Your Health Information Rights
Access
You have the rights to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so.
Disclosure Accounting
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency.)
Alternative Communication
You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment
You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.
Contact Information
If you have any questions or complaints, please contact:
Fruitvale Optometry
3301 E. 12th St. #109
Oakland, CA 94601
(510) 533-6567
Effective date of notice: April 01, 2004
Office Address: 3301 E. 12th St. #109 Oakland, CA 94601
Phone # (510) 533-6567
Fax # (510) 533-6566
This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. Please review it carefully.
General Rule
We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices. Generally, we can only use your health information in our office or disclose it outside of our office, without your written permission, for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.
Uses or Disclosures of Health Information
Examples of how we use information for treatment purposes:
- When we set up an appointment for you
- When our technician or doctor tests your eyes
- When the doctor prescribes glasses or contact lenses
- When the doctor prescribes medication
- When our doctor or associate advises you regarding your glasses or contact lenses
- When we prescribe or refer you for low vision aids
We may disclose your health information outside of our office for treatment purposes, for example:
If we refer you to another doctor or clinic for eye care or low vision aids or services
If we send a prescription for glasses or contacts to another professional to be filled
When we provide a prescription for medication to a pharmacist
When we phone you regarding issues of your glasses or contact lenses
Sometimes we may ask for copies of your health information from another professional that you may have seen before.
We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:
- When our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services.
- When we prepare bills to send to you or your health or vision care plan
- When we process payment by credit card and when we try to collect unpaid amounts due
- When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan
- When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due
We may use and disclose your health information for healthcare operations in a number of ways. Healthcare operations means those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.
Appointment Reminders
We may call to remind you of schedule appointments. We may also call to notify you of other treatments or services available at our office that might help you. We may also contact you to conduct our own surveys about the quality of the products and services we provide.
To You, Your Family and Friends
We must disclose your health information to you, as described in the Your Health Information Rights section of the Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.
Persons Involved in Care
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location or your general condition. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person?s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, photos, or other similar forms of health information.
Required by law
We may use and disclose information about you as required by law. For example, we may disclose information for the following purposes:
- For judicial and administrative proceedings pursuant to legal authority
- To report information related to victims of abuse, neglect or domestic violence
- To assist law enforcement officials in their law enforcement duties or
- To assist public health officials avert a serious threat to the health or safety of you or any other person
Decedents
Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
Organ/Tissue Donation
Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.
Research
We may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.
Government Functions
Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
Workers Compensation
Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation
Marketing Health Products or Services
We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.
Your Authorization
In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Your Health Information Rights
Access
You have the rights to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so.
Disclosure Accounting
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency.)
Alternative Communication
You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment
You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.
Contact Information
If you have any questions or complaints, please contact:
Fruitvale Optometry
3301 E. 12th St. #109
Oakland, CA 94601
(510) 533-6567