We respect our legal obligation to keep private any health information that identifies you. 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.
By law, we must abide by the terms of the Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by the 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 to our website. This notice applies to all paper as well as electronic (Electronic Medical Record) forms of protected health information.
The most common reason why we used 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 medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care, low vision aids, or other services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we disclose the health information for payment purposes are: asking you about your health or vision insurance plans or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or via a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we must 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 health information inside our offices for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.
In some limited situations, law allows or requires us to 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 include:
We may call or write to you to remind you of scheduled appointments, or to notify you 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 could benefit you.
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 needed to continue you proper care or treatment. Sometimes you may initiate the process if it is 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 may 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 use of the disclosure (unless it falls under one of the aforementioned categories where permission is not required by law). If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocation must be in writing and sent to this office.
While we do have a general office email, we highly recommend that all patients refrain from sending any personal health information since it is not a secure format. We recommend that any protected health information be presented in person or via secure fax at 870-244-2021
The law gives you many rights regarding your health information. You can:
If you feel that we have not properly respected the privacy of your health information, you have the right to file a complaint to us or the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you if you make a complaint. If you would like to submit a complaint directly to us, send a written complaint to the office at the address or fax number shown at the top of this notice. If you prefer, you can discuss your complaint in person or via telephone.
By signing this form, you consent to our use and disclosure of your protected health information for treatment, payment, and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures that we have already made in compliance with your prior consent. Nix Eye Care and Surgery provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA).
I agree that the doctor(s) at Nix Eye Care and Surgery may request and use my prescription medication history as well as previous records from other healthcare providers and/or third-party pharmacy benefits payers for treatment purposes.