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.
Giliberti Eye and Laser Center is required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to take reasonable steps to protect the privacy of your Protected Health Information (“PHI”) and to provide you with notice of our legal duties and privacy practices with respect to PHI. Your PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Your PHI includes your prescription records and related information maintained by the Giliberti Eye and Laser Center. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to your PHI.
Giliberti Eye and Laser Center is required to follow the terms of this Notice. We will not use or discloses your PHI without your written authorization, except as described in this Notice. Unless otherwise permitted by applicable laws and rules or by your written authorization, we will not directly or indirectly receive remuneration in exchange for your PHI. We reserve the right to change our privacy practices and this Notice and to make the new Notice effective for your entire PHI we maintain. Any revised Notice will be available at Giliberti Eye and Laser Center and, upon your request; we will provide such revised Notice to you.
Your Health Information Rights
You have the following rights with respect to your PHI:
The right to obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact Giliberti Eye and Laser Center, 415 Totowa Road, Totowa, NJ 07512. You may also obtain a copy of the Notice at our Internet website: www.laserandeye.com.
The right to request a restriction on certain uses and disclosures of your PHI. You have the right to request additional restrictions on our use or disclosure of your PHI by completing the Request for Restriction form and giving it to a Pharmacy associate for review. We are required to agree to a request to restrict the disclosure of your PHI to a health plan if: (A) the disclosure is for the purposes of carrying out payment or health care operations and is not otherwise required by law; and (B) the PHI pertains solely to a health care item or service for which you, or a person on your behalf other than the health plan, has paid the covered entity out-of-pocket in full. We may not be required to agree to all other restriction requests and in certain cases; we may deny your request.
The right to inspect and obtain a copy of your PHI. You have the right to access and copy your PHI contained in a designated record set for as long as we maintain your PHI. The designated record set usually will include prescription and billing records. To inspect or copy your PHI, you must complete the Request for Medical Release form and give it to an associate for review. If the request can be granted, then the associate will provide you with your PHI that we maintain in our designated record set in the form and format requested, if it is readily producible in such form or format or, if not, in a readable hard copy form or electronic form (if contained electronically), or such other format as agreed to by Giliberti Eye and Laser Center and you. You may request that we transmit the copy of your PHI directly to another person, provided you complete the Authorization for Release of Protected Health Information form and give it to an associate for review. Both the Request to Access Protected Health Information form and the Authorization for Release of Protected Health Information form are available upon request. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. We may deny your request to inspect and copy your PHI in certain limited circumstances. If you are denied access to your PHI, you may request that this denial be reviewed.
The right to receive an accounting of disclosures of your PHI. You have the right to receive an accounting of the disclosures we have made of your PHI. This accounting includes only those PHI disclosures required to be accounted for under HIPAA. This accounting is also limited to the time period that these disclosures need to be accounted for under HIPAA. Depending on the compliance date required by law for a particular record, an accounting of the disclosures from an Electronic Health Record will include disclosures for treatment, payment, or health care operations. Records of such disclosures from an Electronic Health Record must be maintained for three years. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations. To request an accounting, you must submit a written request to Giliberti Eye and Laser Center, 415 Totowa Road, Totowa, NJ 07512. Your request must specify the time period, which may not be longer than the time period that these PHI disclosures need to be accounted for under HIPAA. The first accounting you request within a 12 month period will be provided free of charge, but we may charge you for additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
The right to request communications of your PHI by alternative means or at alternative locations. You have the right to request communications of your PHI by alternative means or at alternative locations. For example, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of your PHI, you must complete the Request for Confidential Communications form and give it to an associate for review. If the request can be granted, then the Pharmacy associate will make the appropriate changes. We will accommodate all reasonable requests; however, in case of emergency situations, we may contact you by whatever means we deem necessary.
The right to receive written notification of a breach of your unsecured PHI. You have the right to receive written notification of a breach where your unsecured PHI has been accessed, used, acquired, or disclosed to an unauthorized person as a result of such breach, and the breach compromises the security and privacy of your PHI. Unless specified in writing by you to receive this breach notification by electronic mail, we will provide this notification by first-class mail or, if necessary, by such other substituted forms of communication allowable under the law.
Examples of How We May Use and Disclose Your PHI
The following are descriptions and examples of ways we may use and disclose your PHI:
We may use your PHI for treatment. Treatment is the provision, coordination or management of health care and related services. It also includes, but is not limited to, consultations and referrals between one or more health care providers. For example, we may obtain health information about you from health care providers. We may also discuss your health information and provide your PHI to a prescribing physician or other health care providers as may be necessary for your treatment. We may document in your treatment record information related to the medications dispensed to you and other pharmacy services that we may provide to you. We may exchange your PHI electronically for treatment and other permissible purposes.
We may use your PHI for payment. Payment includes, but is not limited to, actions to make coverage determinations and receive payment (including billing, claims management, subrogation, plan reimbursement and utilization review and pre-authorizations). For example, we may contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of your co-payment. We may also use your PHI to bill you or a third-party payer for the cost of services. The information on or accompanying the bill may include information that identifies you, as well as the prescriptions you are taking.
We may use your PHI for health care operations. Health care operations include, but are not limited to, quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, we may use PHI in your treatment record to monitor the performance of the pharmacists providing treatment to you. The PHI in your treatment records may be used in an effort to continually improve the quality and effectiveness of the health care related services we provide.
We are likely to use or disclose your PHI for the following purposes:
Use of Business Associates: There are some services provided by us through arrangements with our business associates. Examples of our business associates include claims processors or administrators, records administrators, attorneys, pharmacy benefit managers, etc. We may disclose your PHI to our business associates and may allow our business associates to create, receive, maintain, or transmit your PHI in order for the business associates to provide services to us, or for the proper management and administration of the business associates. In addition, our business associates may re-disclose your PHI to business associates who are subcontractors in order for the subcontractors to provide services to the business associates. The subcontractors will be subject to the same restrictions and conditions that apply to the business associates. We may, for example, use a business associate or subcontractor to provide legal services to us, or to bill you or your third-party payer for services rendered. Also, we may use a business associate to maintain your PHI and assist us in responding to a request for records made by you or a third party. To protect your PHI, we require the business associates to agree in writing to appropriately safeguard your PHI.
Communication with individuals involved in your care or payment for your care: Healthcare professionals such as our pharmacists, using their professional judgment, may disclose your PHI to a family member, other relative, close personal friend or any person you may identify, when such communication is relevant to that person’s involvement in your care or payment related to your care.
Health-related communications: We may contact you to provide prescription refill reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Limited data set and de-identified information: We may use or disclose your PHI to create a limited data set or de-identified PHI, and use and disclose such information as permitted by law.
Food and Drug Administration (FDA): We may disclose your PHI to the FDA, or persons under the jurisdiction of the FDA, as may be necessary to enable product recalls, to make repairs or replacements, to conduct post-marketing surveillance or to report information pertaining to adverse events with respect to drugs, foods, supplements, products or product defects.
Workers’ compensation: We may disclose your PHI as authorized by, and as necessary to comply with, laws relating to workers’ compensation or similar programs established by law.
Public health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Law enforcement: We may disclose your PHI for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
As required by law: We must disclose your PHI when required to do so by law.
Health oversight activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs and compliance with civil rights laws.
Judicial and administrative proceedings: If you or your PHI are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order and, under certain conditions, we may also disclose your PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.
In addition, we are permitted to use or disclose your PHI for the following purposes:
Research: We may disclose your PHI to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information has approved their research.
Coroners, medical examiners and funeral directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose your PHI to funeral directors consistent with applicable law to carry out their duties.
Organ or tissue procurement organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose your PHI to notify or assist in notifying a family member, personal representative or another person responsible for your care, your location, and your general condition.
Correctional institution: If you are, or become an inmate of a correctional institution, we may disclose your PHI to the institution or its agents when necessary for your health or the health and safety of others.
To avert a serious threat to health or safety: We may use or disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and veterans: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Protective services for the President and others: We may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Victims of abuse, neglect or domestic violence: We may disclose your PHI to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.
Other Uses and Disclosures of PHI
We will obtain your written authorization before using or disclosing your PHI for the following purposes: (i) most uses and disclosures of psychotherapy notes (to the extent maintained by the Pharmacy); (ii) uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization. When using or disclosing your PHI or requesting your PHI from another covered entity, we will make reasonable efforts to limit such use, disclosure, or request to the minimum necessary to accomplish the intended purpose of such use, disclosure, or request, respectively. We will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for above or as otherwise permitted or required by law. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization. When using or disclosing your PHI or requesting your PHI from another covered entity, we will make reasonable efforts to limit such use, disclosure, or request, to the extent practicable, to the PHI maintained in a limited data set, or if needed, to the minimum necessary to accomplish the intended purpose of such use, disclosure, or request, respectively.
Effective Date: This notice is effective as of March 03, 2015.
