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Providence Eye & Laser Specialists is providing you with our Notice of Privacy Practices. This Summary Notice provides a summary of the Providence Eye & Laser Specialists Notice of Privacy Practices and briefly states:
For a more complete description of our privacy practices, you should carefully review the Detailed Notice of Privacy Practices following this summary. This Summary Notice does not modify or limit the Providence Eye & Laser Specialists Detailed Notice of Privacy Practices. Your Health Information Health
information is any information, we create or receive about you and your
past, present, or future:
How We May Use and Disclose Your Health Information In most cases, your written authorization is needed for us to use or disclose your health information. However, Federal law allows us to use and disclose your health information without your permission for certain purposes, including the following:
A more detailed description of each use and disclosure purpose is included in the Detailed Notice of Privacy Practices, following this summary. All other uses and disclosures of your health information will not be made without your prior written authorization. Your Privacy Rights You have the right to:
Changes We reserve the right to change the Providence Eye & Laser Specialists Notice of Privacy Practices. The revised privacy practices will be effective for all health information we already have about you, as well as information we receive in the future. We will send to your last address of record, and otherwise make available to you, a copy of the revised Notice within 60 days of any change. Complaints If you are concerned that your privacy rights have been violated, you may file a complaint with the practice or to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Providence Eye & Laser Specialists you may contact your Privacy Officer at 704-540-9595 or via the website http://www.providenceeye.com. Complaints do not have to be in writing, though it is recommended. You will not be penalized or retaliated against for filing a complaint. NOTE: A large print version of this
Notice is available upon request. 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. The purpose of this Detailed Notice is to
inform you about your privacy right and provide you with information on
how the Providence Eye & Laser Specialists (PELS) may use and disclose
your health information. All PELS employees, staff, personnel, and
volunteers must follow the terms of this Notice. PELS is required by law
to:
Our Pledge To You We recognize that health information about you is personal. We are committed to protecting the confidentiality of your health information. Your Health Information Health
information is any information we create or receive about you and your
past, present, or future:
Some examples of your health information
are:
Our records containing your health information are the property of PELS. We will give a copy of your health information to you upon your written request, unless prohibited or restricted by law. However, you must follow PELS procedures to obtain the information. In general, we must have your written authorization to use and disclose your protected health information. However, we do not need your authorization to use or disclose your health information in certain circumstances explained in more detail later in this Notice. These circumstances include:
In certain situations we may only use or disclose the minimum amount of health information necessary to accomplish the intended purpose of the use or disclosure. When We May Use and Disclose Your Health Information Treatment We may use and
disclose your health information for treatment. Treatment may include:
Payment We may use and
disclose your health information for payment purposes. This may include:
Health Care Operations We may
use and disclose your health information to support the activities related
to health care, including:
Abuse Reporting We may disclose your health information to report suspected abuse, neglect, or domestic violence to appropriate Federal, State, local, and/or tribal authorities. Health and Safety Activities We may use and disclose your health information when necessary to prevent or lessen a serious threat to the health and safety of the public, yourself, or another person. Any disclosure would only be to someone able to help prevent or lessen the harm. Public Health We may disclose your health information to public health and regulatory authorities, including the Food and Drug Administration (FDA), for public health activities. Public health activities may include:
Judicial or Administrative Proceedings We may disclose your health information for judicial or administrative proceedings if:
Law Enforcement We may disclose your health information for law enforcement purposes when applicable legal requirements are met. These law enforcement purposes may include:
Health Oversight PELS may disclose your health information to a government health oversight agency (e.g. Inspector General (IG) for activities authorized by law, such as audits, investigations, and inspections. Health oversight agencies include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. Coroner or Funeral Services
We may disclose your health information to a funeral director, as
authorized by law. We may also disclose your health information to a
coroner or medical examiner for:
Services We may provide your health information to individuals, companies and others who need to see the information to perform a function or service for PELS, such as a contract. To protect you privacy, we will require these individuals, companies and entities to sign an agreement to protect your privacy. National Security We may use or disclose your health information to authorized Federal officials for conducting national security and intelligence activities. These activities may include protective services to the President and others. Military Activities We may use or disclose your health information, if you are a member of the Armed Forces, for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission, when applicable legal requirements are met. Workers' Compensation We may disclose your health information to comply with workers' compensation laws and other similar programs. Correctional Facilities We
may disclose your health information to a correctional facility if you are
an inmate and disclosure is necessary:
Required by Law We may use or disclose your health information for other purposes to the extent required by Federal law. When Use or Disclosure May or May Not Require You Authorization Research We may use and disclose you health information for research. Before we may use health information for research, all research projects must go through a special PELS approval process in which a research review board, usually called an Institutional Review Board, evaluates the project and its use of health information based on, among other things, the level of risk to you and to your privacy. If you will be seen or provided care as part of the research project, you will be asked to sign a consent form to participate in the project that includes an authorization for use of your information. However, there are times when we may use your health information without an authorization, such as when:
We may disclose your health information for research without an authorization if a research review board (e.g., Institutional Review Board) has approved such action based on a determination that the conduct of the research will cause no more than minimal risk to you and to your privacy. When We Offer You the Opportunity to Decline Use or Disclosure of Your Health Information Family Members or Others Involved in
Your Care
Disclosures to others while you are present; When you are present, or otherwise available, we may disclose your health information to your next of kin, family, or other individuals you identify. For example, your doctor may talk to your spouse about your condition while in the office. Before we make such a disclosure, we will ask if you object. We will not make the disclosure if you object or if we cannot reasonably infer from the circumstances and based on the exercise of professional judgment that you do not object. Disclosers to others when you are
not present; When you are not present, or are unavailable, we
may disclose your health information to your next-of-kin, family, and
others with a significant relationship to you without your authorization
if, in the exercise of professional judgment, we determine the disclosure
is in your best interests. We will limit the disclosure to information
directly relevant to the other person's involvement with you health care
or payment for your health care.
NOTE: We may provide a copy of your medical records to family, next-of-kin, or other individuals involved in your care only if we have your written authorization. Other Uses and Disclosures Prohibited without Your Authorization Other uses and disclosures of your health information not covered by this notice will be made only with your written authorization. If you provide us authorization or permission to use or disclose your health information, you may revoke that permission, in writing at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Please understand that we are unable to take back any uses and disclosures we have already made with your authorization. Your Privacy Rights Right to Request Restriction You may request that we not use or disclose all or part of your health information, including use or disclosures for a particular purpose or to a particular person. However, we are not required to agree to such restriction. To request a restriction, you must submit a written request that identifies the information you want restricted, when you want it to be restricted, and the restrictions that you are requesting. All requests to restrict use or disclosures should be submitted to the PELS Privacy Officer, Department of Veteran Affairs, 810 Vermont Ave. N.W., Washington DC 20420. If we agree to your request, we will honor the restriction unless needed for emergency treatment. Right to Review and Copy Health Information You have the right to review and obtain a copy of your health information in our records. You must submit a written request to our office. Under certain limited situations, you may not be allowed to review or obtain a copy of parts of your health information. If your request is denied, you will be notified of this decision in writing and you may appeal this decision. Right to Request Amendment of Health Information You have the right to request an amendment to your health information in our records if you believe it is incomplete, inaccurate, untimely, or not related to your care. You must submit your request in writing, specify the information that you want corrected, and provide a reason to support your request for amendment. All amendment requests should be submitted to our office. If your request for amendment is denied, you will be notified of this decision in writing. In response you may;
We may prepare a rebuttal to your "Statement of Disagreement". We will provide you with a copy of any such rebuttal. If you have any questions about amending your health information to our records, please contact our office. Right to Request Receipt of Communications in a Confidential Manner You have the right to request that we provide your health information to you by alternative means or at an alternative location. We will accommodate reasonable requests, as determined by PELS policy, from you to receive communications containing your health information:
Contact the PELS to request confidential communications at an alternative address. If the alternative address information results in undeliverable mail, we will resend or mail the communication to your permanent address notated in our computer system. Right to Receive an Accounting of Disclosures You have the right to know what disclosures of your health information have been made from our records other than disclosures we have made to you. Our accounting of disclosures is subject to certain exceptions, restrictions, and limitations. To exercise this right, you must submit a written request to our office. Right To a Printed Copy of the Privacy Notice You have the right to obtain a paper copy of this Notice upon request from our office. You may also obtain a copy of this Notice at our website, http://www.providenceeye.com . 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 health information we already have about you as well as any information we receive in the future. When there is a change to any part of this Notice, we will send to your last address of record a copy of the revised notice within 60 days of the change. The revised Notice will also be available upon request at our office. Complaints If you believe that your privacy rights have been violated, you may file a complaint with PELS or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with PELS you may contact your PELS Privacy Officer by mail, email at http://www.providenceeye.com , or by calling 704-540-9595. Complaints do not have to be in writing, though it is recommended. You will not be penalized or retaliated against for filing a complaint. Contact Information You may contact your PELS Privacy Officer if you have questions regarding the privacy of your health information or would like further explanation of this Notice. The PELS Privacy Officer may be reached by mail at 3025 Springbank Lane, Charlotte, North Carolina 28226 or via telephone at 704-540-9595. Effective Date The privacy practices outlined in this notice are effective in their entirety on April 14, 2003.
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