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Privacy Notice

NOTICE OF PRIVACY PRACTICES

ASSOCIATED RETINAL CONSULTANTS, P.C.

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 ASSOCIATED RETINAL CONSULTANTS, P.C. may use and disclose your protected health information (referred to in this Notice as “PHI”). This Notice also describes our obligations concerning your PHI and describes your rights to access and control your PHI. This Notice has been drafted in accordance with the Privacy Rule, contained in the Code of Federal Regulations at 45 CFR Parts 160 and 164, under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the final rule issued by the Office of Civil Rights of the U.S. Department of Health and Human Services on January 25, 2013 implementing changes to the HIPAA Privacy, Security, Breach Notification, and Enforcement Rules. We are required to: (i) maintain the privacy of PHI provided to us; (ii) provide notice of our legal duties and privacy practices; (iii) abide by the terms of our Notice currently in effect; and (iv) and to notify you following a breach of unsecured PHI. Our goal is to take appropriate steps safeguard any medical or other personal information that is provided to us, and we will abide by the terms of this Notice.

INFORMATION COLLECTED ABOUT YOU

In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:
• Your name, address, social security number, electronic mail address, and phone number.
• Information relating to your medical history.
• Your insurance information and coverage.
• Information concerning your doctor, nurse or other medical providers.
In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your “circle of care” such as the referring physician, your other doctors, your health plan, and close friends or family members. Some or all of this information may be PHI.

HOW WE MAY USE AND DISCLOSE PHI
We may use and disclose PHI for a variety of purposes. All of the types of uses and disclosures of information are described below, but not every use or disclosure in a category is listed.

Required Disclosures. We are required to disclose your PHI to the Secretary of the U.S. Department Health and Human Services, upon request, to determine our compliance with HIPAA and to you, in accordance with your right to access and right to receive an accounting of disclosures, as described below.

For Treatment. We may use your PHI in your treatment. For example, we may use your medical history, such as any presence or absence of diabetes, to assess the health of your eyes.

For Payment. We may use and disclose your PHI to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical condition so that it will pay us for the eye examinations or other services that we have furnished you. We may also need to inform your payer of the treatment you are going to receive in order to obtain prior approval or to determine whether the service is covered.

For Health Care Operations. We may use and disclose your PHI for the general operation of our business. For example, we sometimes arrange for auditors or other consultants to review our practices, evaluate our operations, and tell us how to improve. Or, for example, we may use and disclose your PHI to review the quality of services provided to you.

Public Policy Uses and Disclosures. There are a number of public policy reasons why and when we may disclose your PHI which are described below.

– We may disclose your PHI when we are required to do so by federal, state, or local law.

– We may disclose your PHI in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability, or at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Center for Disease Control, the Food and Drug Administration, the Occupational Safety and Health Administration and the Environmental Protection Agency, to name a few.

– We are also permitted to disclose PHI to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect. Additionally we may disclose PHI to a person subject to the Food and Drug Administration’s power for the following activities: to report adverse events, product defects or problems, or biological product deviations; to track products; to enable product recalls; repairs or replacements; to conduct post marketing surveillance. We may also disclose a patient’s PHI to a person who may have been exposed to a communicable disease or to an employer to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether an individual has a work-related illness or injury.

– We may disclose a patient’s PHI where we reasonably believe a patient is a victim of abuse, neglect or domestic violence and the patient authorizes the disclosure or it is required or authorized by law.

– We may disclose your PHI in connection with certain health oversight activities of licensing and other health oversight agencies which are authorized by law. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which PHI is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which PHI is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which PHI is necessary for determining compliance.

– We may disclose your PHI as required by law, including in response to a warrant, subpoena, or other order of a court or administrative hearing body or to assist law enforcement identify or locate a suspect, fugitive, material witness or missing person. Disclosures for law enforcement purposes also permit use to make disclosures about victims of crimes and the death of an individual, among others.

– We may release a patient’s PHI (1) to a coroner or medical examiner to identify a deceased person or determine the cause of death and (2) to funeral directors. We also may release your PHI to organ procurement organizations, transplant centers, and eye or tissue banks, if you are an organ donor.

– We may release your PHI to workers’ compensation or similar programs, which provide benefits for work-related injuries or illnesses without regard to fault.

– Your PHI also may be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others.

– We may use or disclose certain your PHIr condition and treatment for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your PHI to prepare or analyze a research protocol and for other research purposes.
– If you are a member of the Armed Forces, we may release your PHI for activities deemed necessary by military command authorities. We also may release PHI about foreign military personnel to their appropriate foreign military authority.

– We may disclose your PHI for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release PHI in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or secure a protective order.

– If you are an inmate, we may release your PHI to a correctional institution where you are incarcerated or to law enforcement officials in certain situations such as where the information is necessary for your treatment, health or safety, or the health or safety of others.

– We may disclose proof of immunization to a school where State or other law requires the school to have such information prior to admitting the student, if we obtain an agreement, which may be oral, from a parent, guardian or other person acting in loco parentis for the individual, or from the individual himself or herself, if the individual is an adult or emancipated minor.

– We may disclose PHI for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

Our Business Associates. We sometimes work with outside individuals and businesses, called business associates, to perform various functions on its behalf. For example, we may contract with a service provider to perform the administrative functions necessary to pay your medical claims. To perform these functions or to provide the services, business associates may receive, create, maintain, use, and/or disclose PHI, but only after we and the business associate agree in writing to contract terms requiring the business associate to appropriately safeguard the privacy and security of your PHI.

Disclosures to Persons Assisting in Your Care or Payment for Your Care. We may disclose information to individuals involved in your care or in the payment for your care. This includes people and organizations that are part of your “circle of care” such as your spouse, your other doctors, or an aide who may be providing services to you. We may also use and disclose PHI about a patient for disaster relief efforts and to notify persons responsible for a patient’s care about a patient’s location, general condition or death. Generally, we will obtain your verbal agreement before using or disclosing PHI in this way. However, under certain circumstances, such as in an emergency situation, we may make these uses and disclosures without your agreement.

Appointment Reminders, Test Results, Billing. We (or our health insurance issuers, HMOs, business associates, or third party administrators) may use and disclose medical information to contact you by phone, U.S. postal mail or electronic mail as a reminder that you have an appointment or that you should schedule an appointment. We may use and disclose medical information to contact you by phone, electronic mail or U.S. postal mail with any test results, billing statements and inquiries, reminders, and/or questions.

Treatment Alternatives. We (or our health insurance issuers, HMOs, business associates, or third-party administrators) may use and disclose your PHI in order to tell you about or recommend possible treatment options, alternatives or health related services that may be of interest to you. You may be contacted either by phone, U.S. postal mail or electronic mail. With limited exceptions, where the making of such communications involves receipt of financial remuneration by us, we must obtain your authorization for any use or disclosure of PHI.
Fundraising. We may contact you by phone, U.S. postal mail or electronic mail in an effort to raise funds for our operations and you have the right to opt out of receiving such communications.

OTHER USES AND DISCLOSURES OF PERSONAL INFORMATION

We are required to obtain written authorization from you for any other uses and disclosures of PHI other than those any such notes), uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. If you provide us with such an authorization, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization, except to the extent we have already relied on your original authorization.

INDIVIDUAL RIGHTS

The following is a description of your rights with respect to your PHI.
Right to Request a Restriction. You have the right to request a restriction on the PHI we use or disclose for treatment, payment or health care operations. You also have a right to request a limit on disclosures of your PHI to family members or friends who are involved in your care or the payment for your care. Your request must include the PHI you wish to limit, whether you want to limit our use, disclosure, or both, and (if applicable), to whom you want the limitations to apply (for example, disclosures to your spouse). You may request such a restriction using the Contact Information at the end of this Notice.

We are not required to agree to any restriction that you request, except that we must agree to a request to restrict disclosure of PHI to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the PHI pertains solely to a health care item or service for which you, or a person other than the health plan on behalf of the individual, has paid us in full. If we agree to the restriction, we will not use or disclose PHI in violation of such restriction, except that, if the individual who requested the restriction is in need of emergency treatment and the restricted PHI is needed to provide the emergency treatment, we may use the restricted PHI, or may disclose such information to a health care provider, to provide such treatment to the individual. If restricted PHI is disclosed to a health care provider for emergency treatment, we shall request that such health care provider not further use or disclose the information. We may terminate its agreement to a restriction if 1) you agree to or request the termination in writing, 2) you orally agree to the termination and the oral agreement is documented; or 3) we notify you that we are terminating our agreement to a restriction, except that such termination is not effective with respect to PHI for which we must agree to a restriction as described above and is only effective with respect to PHI created or received after we provided such notice.

Right to Request Confidential Communications. You have the right to request that we communicate with you in an alternative manner or at an alternative location. For example, you may ask that all communications be sent to your work address. You must request a confidential communication in writing using the Contact Information at the end of this Notice. Your request must specify the alternative means or location for communication with you. We will accommodate a request for confidential communications that is reasonable, but may condition it on, when appropriate, information as to how payment, if any, will be handled.

Right to Request Access. You have the right to inspect and copy PHI that may be used to make decisions about your benefits. You must submit your request in writing. For your convenience, you may request a form using the Contact Information at the end of this Notice. If you request copies, we may charge you copying and postage fees as allowed by law. Note that under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to law that prohibits access to PHI. In some, but not all, circumstances, you may have a right to have a decision to deny access reviewed.

Right to Request an Amendment. You have the right to request an amendment of your PHI held by us if you believe that information is incorrect or incomplete. If you request an amendment of your PHI, your request must be submitted in writing using the Contact Information at the end of this Notice and must set forth a reason(s) in support of the proposed amendment. In certain cases, we may deny your request for an amendment. For example, we may deny your request if the information you want to amend is accurate and complete or was not created by us. If we deny your request, you have the right to file a statement of disagreement. Your statement of disagreement will be linked with the disputed information and all future disclosures of the disputed information will include your statement
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Right to Request an Accounting. You have the right to request an accounting of certain disclosures we have made of your PHI. You may request an accounting using the Contact Information at the end of this Notice. You can request an accounting of disclosures made up to six years prior to the date of your request, except that we are not required to account for disclosures made prior to April 14, 2003. You are entitled to one accounting free of charge during a twelve month period. There will be a charge to cover our costs for additional requests within that twelve-month period. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to accept this Notice electronically. To obtain such a copy, please contact us using the Contact Information at the end of this Notice.

You may also obtain a copy of this form at our web site at: www.associatedretinalconsultants.com

Right to Receive Notifications of Breaches of Unsecured PHI. You have the right to and will receive notifications of breaches of your unsecured PHI.

CHANGES TO THIS NOTICE

We reserve the right to make changes to this notice at any time. We reserve the right to make the revised notice effective for PHI we have about you as well as any PHI we receive in the future. In the event there is a material change to this Notice, the revised notice will be posted. In addition, you may request a copy of the revised notice at any time.

EXERCISING YOUR RIGHTS / COMMENTS / COMPLAINTS

To exercise any of your rights, to obtain more information concerning this Notice, or if you have a complaint concerning our privacy practices, please submit all requests, inquiries and complaints in writing to:

Privacy Official
Associated Retinal Consultants, P.C.
39650 Orchard Hill Place, Suite 200
Novi, Michigan, 48375

You may also complain to the Secretary of the U.S. Department of Health and Human Services, at:

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Fax: (312)886-1807

YOU WILL NOT BE RETALIATED AGAINST OR PENALIZED BY US FOR FILING A COMPLAINT.

This Notice is effective as of April 14, 2003.
First Revision Date: September 1, 2012.
Second Revision Date (Compliance with Final Rule): September 23, 2013