Eye Care for the Adirondacks
NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003

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.

This notice describes our Practice’s privacy policies, which extend to:

• Any health care professional authorized to enter information into your chart (including physicians, RNs, etc.);
• All areas of the Practice (front desk, administration, billing and collection, etc.);
• All employees, staff and other personnel that work for or with Eye Care for the Adirondacks (ECFTA);
• Our business associates (including a billing service, or facilities to which we refer patients), on-call physicians, and so on.

ECFTA provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION:

We understand that your medical information is personal to you, and we are committed to
protecting this information about you. As our patient, we create paper medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:

Your health record is the physical property of Eye Care for the Adirondacks. The information contained in the record, however, belongs to you. You have the right to:

• Request a restriction or limitation on the medical information we use or disclose about you for your treatment, payment or health care operations. For example, you may request that a particular procedure be kept confidential and not shared with other providers. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend or when we notify a family member, personal representative or other person responsible for your care to inform them of your location and general condition. We are not required to agree to your requested restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

• Obtain a copy of this Notice by requesting one from the Administrator.

• Inspect and obtain a copy of your health care record by submitting a request in writing to the Administrator of ECFTA.

• Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting, in writing, that an amendment be made. You must provide a reason that supports your request.

• Obtain a report of all of the disclosures of your health information that we have made.

• Request that we communicate with you about your medical information in a certain way or at a certain location within reasonable limits.

• Revoke your authorization to use and disclose medical information about you, except to the extent that we have already used or disclosed your medical information.

OUR RESPONSIBILITIES REGARDING YOUR MEDICAL INFORMATION

We are required by law to:

• Maintain the privacy of your health information.

• Provide you with this Notice, which describes our legal duties and privacy practices with respect to information we collect about you and a revised copy of the Notice if it is amended or otherwise changes.

• Abide by the terms of this Notice.

• Notify you if we are unable to agree to a requested restriction.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

Each time you visit us, a record of your visit is made. We may use or disclose the health information contained in this record to certain employees and staff members of ECFTA or certain persons or entities outside the ECFTA in certain situations without first obtaining your authorization. The following categories describe the different ways that we may use and disclose your medical information. We must obtain your prior written authorization before using or disclosing your medical information in all other situations that are not listed below.

Treatment. We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, or other Eye Care for the Adirondacks personnel who are involved in taking care of you at ECFTA. For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health team. Members of your health care team will then record the actions that they took and their observations. By reading your medical record, the physician will know how you are responding to treatment.

Payment. We may use and disclose medical information about you so that the treatment and services you receive at ECFTA may be billed to and payment may be collected from you, an insurance company, or third party. For example, we may need to give your insurance company information about care you received at ECFTA so that the insurance company will pay us or reimburse you for care you received.

Health Care Operations. We may use and disclose medical information about you so we can run our surgery center efficiently and to make sure that all our patients receive quality care. These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, and deciding whether certain new treatments are effective. We may also use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for purposes of helping us to comply with legal requirements, to auditors to verify our records, to billing companies to aid us in this process and the like.

Appointment and Patient Recall Reminders. We may ask that you sign in writing at the Receptionist’s desk, a “Sign In” log on the day of your appointment. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at ECFTA or that you are due to receive periodic care at ECFTA. This contact may be by phone, in writing, e-mail or otherwise and may involve leaving an e-mail, a message on an answering machine, or otherwise which could be received or intercepted by others.

Treatment Alternatives. We may use and disclose medical information about you to contact you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose your medical information to inform you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. We must inform you that we are going to use or disclose your information for this purpose and provide you with an opportunity to agree to, restrict or object to the disclosure or use.

Notification. We may use or disclose your medical information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your location and general condition. We must inform you that we are going to use or disclose your information for this purpose and provide you with an opportunity to agree to, restrict or object tot he disclosure or use.

As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.

Avert Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. ECFTA, however, will only disclose the information to someone able to help prevent the threat.

Organ and Tissue Donation. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or organs for the purpose of tissue donation and transplant.

Business Associates. Some of the services provided at ECFTA are provided by business associates. For example, we utilize certain laboratories to perform lab tests. When we utilize these services, we may disclose your health information to our business associates so that they can perform the job we asked them to do. To protect your health information, we require our business associates to appropriately safeguard your information.

Workers’ Compensation. We may release medical information about you to the extent authorized by and to the extent necessary to comply with the laws relating to workers’ compensation or other similar programs established by law.

Public Health Risks. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure and disciplinary action that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner for purposes of identifying a deceased, determining a cause of death, or other duties authorized by law. We may also disclose health information to funeral directors consistent with applicable law to carry our their duties.

Food and Drug Administration. We may disclose to the FDA health information related to adverse events with respect to food, supplements, products and product defects, or post marketing surveillance information or to enable product recalls, repairs, or replacement.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

Victims of Abuse, Neglect or Domestic Violence. We may release medical information to a government authority if we reasonably believe that you are a victim of abuse, neglect or domestic violence, to the extent authorized by law. We must inform you or your personal representative that we have disclosed information for this purpose unless we believe that telling you or your personal representative would place you in risk of serious harm or otherwise not be in your best interest.

Child Abuse. We may release medical information to a government authority authorized by law to receive reports of child abuse or neglect.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only upon a specific written authorization that you provide to us. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation, however, will not have any effect on any action ECFTA took before it received the revocation.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the office. The notice will contain on the first page, in the top right-hand corner, the date of last revision and effective date. In addition, each time you visit ECFTA for treatment or health care services you may request a copy of the current notice in effect.

QUESTIONS OR COMPLAINTS

If you have questions and would like additional information, you may contact Anne Van Leeuwen, Administrator, 566-2020.

If you believe your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation to Anne Van Leeuwen, Administrator, 450 Margaret St, Plattsburgh, NY 12901 or to the Secretary of Health and Human Services in Washington, D.C. You will not be penalized for filing any complaint