Notice of Privacy Practices

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.

This Notice of Privacy Practices (“Notice”) describes how Trepke Vision Care (“we,” “us,” or “our”) may use and disclose your protected health information (“PHI”) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access your PHI. In general, PHI is information about you, including demographic 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.

Responsibilities of Trepke Vision Care

We are required by law to maintain the privacy of PHI, to provide you with notice of our legal duties and privacy practices with respect to PHI, and to notify you in the event that we discover a breach of unsecured PHI.

We are required to abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice at any time, and any material changes to the Notice will be posted in our facility and on our website: http://www.trepkevisioncare.com/. The new Notice will be effective for all PHI that we maintain. We will make the revised Notice available in writing at your next visit following the effective date of the change. You may obtain a copy of the Notice currently in effect by contacting our Privacy Officer at (440) 878-0122 or in writing at 20914 Drake Road, Strongsville, Ohio 44149.

Acknowledgment of Receipt of This Notice

You will be asked to provide a signed acknowledgment of receipt of this Notice. Our intent is to make you aware of the possible uses and disclosures of your PHI and your privacy rights. The delivery of health care services will not be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your PHI for treatment, payment, and health care operations when necessary.

How We May Use or Disclose Your Protected Health Information

Treatment, Payment, and Health Care Operations
We may use and disclose PHI for the purposes of treatment, payment, and health care operations without your written permission, in most cases. Examples of the uses and disclosures that we may make for these purposes include the following:

Treatment refers to the provision, coordination, or management of health care and related services by one or more health care providers. We may use and disclose your PHI to provide the treatment you require. We may, as necessary, disclose your PHI to discuss your health with other health care providers involved in your treatment, such as an ophthalmologist performing cataract surgery. PHI related to your treatment obtained by us may be recorded in your medical record. Other examples of how we use and disclose your PHI for treatment purposes include: setting up an appointment for you; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; referring you to another health care provider 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.

Payment refers to activities we undertake to obtain reimbursement for your health care services, including asking about your health or vision care plans or other sources of payment. Payment includes activities such as determinations of eligibility or coverage. We may use and disclose your PHI to others for purposes of receiving payment for prescription medications and vision services you receive. For example, we may use and disclose your PHI to prepare and send a claim or a bill to you, your family, or a third-party payor, such as an insurance company or health plan. The information on the claim or bill may contain information that identifies you, your diagnosis, and other treatment or supplies used in the course of treatment. We may also use and disclose your PHI to attorneys or collection agencies to collect unpaid amounts.

Health Care Operations refers to the basic business functions necessary to operate as a health care provider. We may use or disclose, as needed, your PHI in order to support business activities, including training, licensing, legal services, auditing, business planning, business management activities, and conducting or arranging for other business activities. For example, your PHI may be disclosed to other health care providers involved with your care, quality improvement personnel, and others to: assess the quality of the care we provide, make personnel decisions, defend ourselves in legal matters, or perform financial audits.

Communications Regarding Prescriptions
We may use your information to communicate about a device (i.e., contact lenses), drug, or biologic that is currently being prescribed, or to provide information about treatment alternatives or health-related products and services that may be of interest to you.

Other Uses and Disclosures Allowed Without Your Authorization
Federal law also allows or requires us to use and disclose PHI, without your written authorization, in certain limited situations, unless the use or disclosure is prohibited by a more stringent state law. Examples of permitted uses and disclosures of your PHI are listed below.

Public Health Activities We may disclose your PHI for public health activities in certain situations and as required by law. For example, we may use or disclose your PHI to: prevent disease, help with product recalls, or report adverse reactions to medications.

Victims of Abuse, Neglect, or Domestic Violence We may disclose your PHI in certain circumstances to government authorities authorized by law to receive reports of abuse, neglect, or domestic violence, if we reasonably believe you to be a victim of abuse, neglect, or domestic violence.

Health Oversight Activities We may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations; audits; inspections; licensure and disciplinary actions; civil, administrative, or criminal actions; or other activities necessary for the government to oversee the health care system, government benefits programs, government regulatory programs, and compliance with civil rights laws.

Lawsuits and Administrative Proceedings We may disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or administrative proceeding, or as required by law. In some cases, we may also disclose your PHI in response to a discovery request, subpoena, or other lawful process.

Law Enforcement We may disclose PHI for law enforcement purposes, to a law enforcement official, if certain conditions are met.

Deceased Patients We may disclose PHI to a coroner or medical examiner to identify a deceased person, determine the cause of death, or other duties as authorized by law. If necessary, we may disclose PHI to funeral directors to perform their duties, as authorized by law.

Organ, Eye, or Tissue Donations If you are an organ donor, we may use or disclose your PHI to an organ procurement organization or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue as necessary to facilitate organ, eye, or tissue donation and transplantation.

Research We may use and disclose your PHI for research purposes in limited circumstances, such as upon the approval by an Institutional Review Board of an alteration to or waiver of your authorization for the use or disclosure of your PHI and the receipt of certain representations from the researcher.

Serious Threats to Health or Safety Consistent with applicable laws, we may use and disclose your PHI if we, in good faith, believe the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person(s) reasonably able to prevent or lessen the threat. In certain circumstances, we also may use or disclose your PHI if we, in good faith, believe the use or disclosure is necessary for law enforcement authorities to identify or apprehend an individual.

Specialized Government Functions We may use and disclose your PHI if you are a member of the Armed Forces or a foreign military, if certain criteria are met. We may disclose your PHI to authorized federal officials for the conduct of intelligence, counter-intelligence, and national security activities authorized by law. We may also disclose your PHI to authorized federal officials to protect the President, authorized officials, or foreign heads of state, or to conduct investigations authorized by law.

Inmates We may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate or under the lawful custody of a law enforcement official, in certain circumstances, such as health care, health, and safety.

Workers’ Compensation We may disclose your PHI as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

De-Identified Information We may disclose PHI that does not personally identify you and with respect to which there is no reasonable basis to believe that the information can be used to identify you.

Business Associates We may share your PHI with business associates that perform various activities (e.g., billing, legal services) on our behalf, and that provide certain types of services that involve PHI.

Uses and Disclosures for Involvement in Your Care and Notification Purposes
We may make such uses and disclosures if we obtain your verbal agreement to do so; if we give you an opportunity to object to such a disclosure and you do not raise an objection; if we reasonably infer from the circumstances that you do not object to the disclosure; and, in certain circumstances (including incapacity and emergencies) where we are unable to obtain your agreement and we determine the disclosure is in your best interests.

Notification Purposes
We may use or disclose PHI to notify or assist in the notification of a family member, personal representative, or other person responsible for your care of your location, general condition, or death. We may use or disclose your PHI to an authorized public or private entity for the purpose of coordinating with disaster relief efforts. In the event that an individual is deceased, we may use or disclose to a family member or other persons described above, the PHI that is relevant to such person’s involvement in the deceased’s care or payment for health care prior to the person’s death.

Additional Ohio Requirements
Ohio has laws and regulations that provide additional privacy protections regarding the release of specific types of your PHI, including treatment records of services for mental illness, alcoholism, or drug dependence. Ohio law requires your written consent for disclosures of records relating to the administration of drugs and patient-specific drug or pharmacy transactions. Not all disclosures listed in the Ohio law are applicable to Trepke Vision Care. However, we will only provide such records to the following individuals, unless you provide us with your signed and dated consent to share such records with other individuals:

(1) you (the patient);
(2) the prescriber who issued the prescription or medication order;
(3) certified/licensed health care personnel who are responsible for your care;
(4) a member, inspector, agent or investigator of the state board of pharmacy or any federal, state, county, or municipal officer whose duty is to enforce Ohio or federal laws relating to drugs and who is engaged in a specific investigation involving a designated person or drug;
(5) an agent of the state medical board when enforcing Ohio laws regarding physician assistants and limited practitioners;
(6) an agency of government charged with the responsibility of providing medical care for the patient upon a written request by an authorized representative of the agency requesting such information;
(7) an agent of a medical insurance company who provides prescription insurance coverage to the patient upon authorization and proof of insurance by the patient or proof of payment by the insurance company for those medications whose information is requested;
(8) an agent who contracts with the pharmacy as a business associate; and
(9) an agent of the state board of nursing when enforcing laws governing nurses.

Other Uses and Disclosures of PHI With Your Written Authorization
Other uses and disclosures of your PHI not described in the Notice will be made only with your valid written authorization, unless otherwise permitted or required by law. You may revoke your authorization at any time by providing written notice to the address below. Your written revocation will only be effective for future uses and disclosures of your PHI; revocation of your authorization shall have no effect on uses or disclosures made before your withdrawal of the authorization. We will not use your PHI for fundraising or sell your PHI. We will only use your PHI for marketing purposes if you give us written permission. We do not create or maintain psychotherapy notes at Trepke Vision Care.

Your Rights Regarding Your Protected Health Information

As a patient, you have rights with respect to your PHI, including:

Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit certain uses and disclosures of your PHI. Any such request must be made in writing to the Privacy Officer listed in this Notice. Your request must state the specific restriction requested and to whom that restriction would apply.

We are not required to agree to any restriction that you request, except if (1) the disclosure is to a health plan for the purpose of carrying out payment or health care operations and is not otherwise required by law and (2) the PHI pertains solely to a health care item or service for which we have been paid in full by you or a person other than the health plan.

Right to Receive Confidential Communications
You have the right to request that communications involving PHI be provided to you at an alternative location or by an alternative means of communication. For example, you can ask that we only contact you at work or by mail. We must accommodate reasonable requests. Requests must be made in writing to the Privacy Officer listed in this Notice, and, when appropriate, you must specify how payment will be handled and an alternate address or other method of contact.

Right to Access Your PHI
You have the right to inspect and obtain a copy of certain types of your PHI contained in a designated record set for as long as the PHI is maintained in the designated record set. A designated record set is a group of records maintained by or for us, such as medical, billing, or payment record systems, or those records that are used, in whole or in part, by or for us, to make decisions about individuals.

To inspect and copy your PHI, contact the Privacy Officer. We may deny your request to inspect and copy your PHI in certain circumstances. If you are denied access to your PHI, you will be provided with a written denial. If you request a copy of your PHI, we may charge a reasonable fee to copy any PHI that you have the right to access.

Right to Amend PHI
You have the right to request that we amend PHI or a record in a designated record set for as long as the PHI is maintained in the designed record set. We may deny your request for amendment in certain circumstances, such as if we determine that the PHI is accurate and complete. Requests for an amendment of your PHI should be made in writing to the Privacy Officer listed in this Notice.

Right to Receive an Accounting of Disclosures
You have the right to receive an accounting of certain disclosures of your PHI that we have made, if any, in the six years prior to the date of your request. We are not required to give you an accounting of certain disclosures, such as disclosures for treatment, payment, or health care operations. Requests for an accounting of disclosures of your PHI should be directed to the Privacy Officer listed in this Notice.

Right to Receive a Paper Copy of this Notice Upon Request
You have the right to receive a paper copy of this Notice upon request. If you allow us, we may send you this Notice by e-mail, and you still may obtain a paper copy of the Notice upon request. Requests for a paper copy of this Notice should be directed to the Privacy Officer listed in this Notice.

Privacy Complaints

You may file a complaint with us and the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with us, send written notice to the Privacy Officer at the address listed below. We will not retaliate against you for filing a complaint.

Contact Information

If you have questions about this Notice of Privacy Practices, contact our Privacy Officer at (440) 878-0122 or at 20914 Drake Road, Strongsville, Ohio 44149, for further information about the matters covered by this Notice.

Effective Date

October _01_, 2014.