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Notice of Privacy Practices
Longmont Vision Center
Dr. Phillip Baker And Dr. Roger Trudell, FAAO, FCOVD
412 Main Street
Longmont, Co 80501
Ph: 303-651-6700 Fax: 303-651-6702 Email: doctortrudell@aol.com
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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.
_____________________________________________________________________________________________
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 will ask you for special written
permission.
We will ask for special written permission in the following situations: 1.
Research 2. Marketing 3. Selling your PHI
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 and disclosures to prevent a serious threat to health or safety;
* 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;
* specify other uses and disclosures affected by Colorado state law.
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 you will give us a
properly completed authorization form, or you will 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 Dr. Roger Trudell at the business address.
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 Dr. Roger Trudell at the phone number/address/email listed above.
* 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 Dr. Roger Trudell at
the phone number/address/email listed above.
* 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 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 Dr. Roger Trudell at the address,
phone number or email listed above.
* 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 Dr. Roger Trudell at the address, fax or E-mail
shown at the beginning of this Notice.
* get a list of the disclosures that we have made of your health information
within the past six years (or a 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 Dr. Roger Trudell at the address, fax or
E-mail 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 Dr. Roger Trudell at the address, fax or E-mail
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
Dr. Roger Trudell at the phone number/address/e-mail listed above or visit him
personally at the office.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit Dr.
Roger Trudell at the phone number/address/email listed above.
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ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I have received a copy of Dr. Phillip Baker/Dr. Roger Trudell’s
Notice of Privacy Practices:
Patient Name: ______________________________ Signature:
___________________________________ Date: ________________
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