Notice Regarding Compliance with HIPAA
Please review this carefully before signing.
This notice, which is required by the federal Health Insurance
Portability and Accountability Act of 1996 (HIPAA),
informs you about our privacy practices. HIPAA is a federal
program that requires that all medical records and other
individually identifiable health information used or disclosed by
us in any
form, whether
electronically,
on paper or
orally,
are kept properly
confidential.
This Act gives
you, the
patient,
significant new rights
to understand and control how your health information is used. HIPAA
provides penalties for covered entities that misuse personal health
information.
We
are required by law to maintain privacy of your health information
and give you this
Notice concerning this
practice. We will keep
your
health information confidential,
and with signing
this Notice,
your health information will only be
used
for the following purposes:
Treatment: We may use or disclose your health information to a
physician or other health care provider providing treatment to you
now or in the future.
Payment: We may use and disclose your health information for
reimbursement
of services we provide to
you.
Health
Care Operations: We may use and disclose your health information in
connection with our health care operations. Health care operations
include quality assessment and improvement activities,
conducting training programs,
accreditation,
or certification.
Appointment Reminders:
We may use or disclose
your health
information to provide appointment reminders or other health-related
benefits and services,
including,
but not limited
to, voicemail messages, letters,
postcards, FAX
or email.
Our
Laboratory:
Our laboratory is an open atmosphere. You will be able to visually
see staff and
other patients and conversations may be
over-heard.
No personal or
health- related information will be disclosed to other patients
without prior approval.
We may ask you to speak with other patients (like
children who are unsure), but you are
not obligated to do so if it makes you uncomfortable. We are also
educators in ocularistry and may have observers.
Disclosure:
We may disclose and/or share your healthcare information with other health care
professionals who provide treatment and/or service
to you or for consultation. These professionals will have a privacy
and confidentiality policy like this one. Health information
about you may also be disclosed to your family,
friends and/or
other persons you choose to involve in your care if you agree to it.
We may also create and distribute de-identified health information
by removing all references to individually identifiable information.
Our
Legal Duty:
We reserve the right to change our privacy
practices concerning
all health information we maintain provided such changes are
applicable by
law. If any
changes are made,
we will change this Notice and make a new Notice available upon request.
You may request
a copy of our Notice at any time.
We may, without
prior consent,
use or disclose protected health information to carry
out treatment,
payment
or
health
care operations in the following
circumstances:
Emergencies:
If
you are incapacitated
we will use our professional judgment to disclose only that
information directly relevant to
your
case. This
includes
contacting someone
responsible
for your
care or health-related
information or supplies
(example
Rx)
unless you
have advised us otherwise.
Legally:
We may
disclose your
health information
when
we are required to do so by law
or
lawful process.
We may also disclose
information if requested
by State or
Federal
officials.
Abuse
or Neglect: We may
disclose your
health
information to appropriate
authorities if
we
reasonably believe
that
you
are a
possible victim of
abuse,
neglect,
or domestic violence
or the possible victim of
other crimes to
prevent a serious threat to your health
or safety or
that of others.
You have the following
rights with respect to
your protected health information,
which you can exercise
by presenting a written request:
Restrictions:
The right to request restrictions on certain uses and
disclosures
of protected
health information, including those related to disclosures to family,
friends
or any other person identified by
you.
We are not required to agree to a requested restriction. If we do
agree to a
restriction,
we must abide
by
it unless you
agree in
writing
to remove it.
Contact:
The right to a reasonable request to
receive confidential communications
of protected health information from us by
alternative
means or at alternative
locations.
Other:
You have the
right to amend your
protected health information. You have
the right to
receive an accounting disclosure
of your health information. You have the
right
to obtain a paper
copy of
this
notice upon request.
You have the right to file a formal
complaint.
Paper Copy:
You have the right to request a paper copy of this notice from the
front desk or request a copy be sent to you. This notice can also be
downloaded from our website.(privacy-practices)
How to Contact
Us:
Iowa Eye
Prosthetics,
Inc.
625 1st
Avenue
Suite #200
Coralville,
IA 52241
319-354-3434
319-354-3465 FAX
ACKNOWLEDGEMENT
OF RECEIPT
OF NOTICE
I acknowledge that I have received a
copy
of Iowa Eye Prosthetics,
Inc.'s
Notice of Privacy Practices.
PATIENTS
PRINTED
NAME
PATIENTS SIGNATURE
DATE
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