1684 N. Prospect Ave.
Phone 414-271-2020
Fax 414-272-3932
Effective
date of notice: 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.
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 our 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 will ask you for special written permission when law requires
it.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT
PERMISSION
In 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:
·
When a state or federal law mandates that certain health
information be reported for a specific purpose;
·
For 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;
·
Disclosures to governmental authorities about victims of
suspected abuse, neglect, or domestic violence;
·
Uses 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;
·
Disclosures for judicial and administrative proceedings,
such as in response to subpoenas or orders of courts or administrative
agencies;
·
Disclosures 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;
·
Disclosure 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;
·
Uses or disclosures for health related research;
·
Uses 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;
·
Disclosures of de-identified information;
·
Disclosures 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.
Unless
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 we will ask you
to give us a properly completed authorization form.
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 address listed at the
beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health
information. You can:
·
Ask 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 address or fax number shown at the beginning of the Notice.
·
Ask 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 Milwaukee Eye Care Associates S.C’s Privacy Officer at the
address or fax number shown at the beginning of this Notice.
·
Ask 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 60 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 Milwaukee Eye Care
Associates S.C’s Privacy Officer at the address or fax number shown at the
beginning of this Notice.
·
Ask 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 Milwaukee Eye Care Associates S.C’s Privacy Officer at the
address or fax number shown at the beginning of this Notice.
·
Get 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 Milwaukee Eye Care Associates S.C’s Privacy Officer at the
address or fax number 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 Milwaukee Eye Care Associates S.C’s
Privacy Officer at the address or fax number 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, please
contact Milwaukee Eye Care Associates S.C’s Privacy Officer using the address
or phone number shown at the beginning of this Notice.
03/24/03