Notice of Privacy Practices for Cataract & Laser Institute

Effective date of notice: 07/12/13 
NOTICE OF PRIVACY PRACTICES 
Cataract & Laser Institute 
Privacy Officer 
P.O. Box 549 
Wabash, IN 46992 

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. 

CLI respects its legal obligation to keep health information that identifies you as private. CLI is obligated by law to give you notice of its privacy practices. This Notice describes how CLI protects your health information and what rights you have regarding it. 

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS 
The most common reason why CLI uses or discloses your health information is for treatment, payment or health care operations. Examples of how CLI uses or discloses information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic 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. Examples of how CLI uses or discloses your health information for payment purposes are: asking you about your health care plans, or other sources of payment; preparing and sending bills or claims, or collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that CLI has to do in order to run its office. Examples of how CLI uses or discloses 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. 

CLI routinely uses your health information inside its office for these purposes without any special permission. If CLI needs to disclose your health information outside of its office for these reasons, it usually will not ask you for special written permission. 

CLI will ask for special written permission in the following situations; contact lens prescriptions; access to medical records by the patient, access to medical records of a minor, mental health records, communicable diseases records, alcohol and drug abuse records, and health records to accident and sickness insurance companies. 

PATIENT REQUEST FOR COST OF SERVICE ESTIMATE
You may ask our front desk staff for an estimate of the amount you will be charged for a nonemergency medical service provided in this office. Once requested, the estimate will be provided to you within five business days.

USES & DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires CLI to use or disclose your health information without your permission. Not all of these situations will apply to CLI; some may never come up at CLI at all. Such uses or disclosures are: 

  • when a state of federal law mandates that certain health information be reported for a specific purpose; 
  • for public health purposes, such as contagious disease reporting, investigation or surveillance and for notices to and from federal Food and Drug administration regarding drugs or medical devices, coordinating care in event of a disaster through Disaster Relief Organizations.
  • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; 
  • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid, or for investigation of possible violations of health care laws;  
  • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;  
  • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else;  
  • disclosure to a medical examiner to identify a dead person or to determine the cause of death; to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;  
  • uses or disclosures for health related research; 
  • uses and disclosures to prevent a serious threat to health or safety;  
  • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes, or for the evaluation and health of members of the Foreign Service; 
  • disclosures of de-identification information; 
  • disclosures relating to worker’s compensation programs;  
  • disclosures of a “limited data set” for research, public health, or health care operations;  
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; 
  • disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information; 
Unless you object, CLI will also share relevant information about your care with your family or friends who are helping you with your eye care. 

APPOINTMENT REMINDERS 
CLI may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. CLI may also call or write to notify you of other treatments or services available at its office that may help you. Unless you tell CLI otherwise, CLI will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. 

FUNDRAISING & MARKETING 
CLI may use or disclose to a business associate or to an institutionally related foundation, demographic information and dates of care relating to you without your authorization. Upon receiving any written fundraising communication, you may elect to “opt out” of any further such communication. Any such elect shall be treated as a revocation of authorization. To make such election send a written request to the CLI privacy officer at the address shown above. Your authorization will be obtained prior to CLI sending any marketing material to you that will result in financial remuneration to CLI. 

OTHER USES AND DISCLOSURES 
CLI will not make any other uses or disclosures of your health information unless you sign a written authorization. The content of the authorization is determined by federal law. Sometimes, CLI may initiate the authorization process if the use or disclosure is its idea. Sometimes, you may initiate the process if it is your idea for CLI to send your information to someone else. Typically, in this situation you will give CLI a properly completed authorization. 

If CLI initiates the process and asks you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, CLI cannot make the use or disclosure. If you do sign an authorization, you may revoke it at any time unless CLI has already acted in reliance upon it. Revocations must be in writing. Send them to the CLI privacy officer at the address shown above. 

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 
The law gives you many rights regarding your health information. You can: 
ask CLI to restrict its uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. CLI does not have to agree to this, but if it agrees, CLI must honor the restrictions that you want. To ask for a restriction, send a written request to the CLI privacy officer at the address shown above. 
You can, however, request that CLI restrict the disclosure of your PHI to a health plan if you have paid out-of-pocket fully and CLI must honor it. 
Have access to an electronic copy of your healthcare records when PHI is maintained in electronic format. 
ask CLI to communicate with you in a confidential way, such as by phoning you at work rather than at home or by mailing health information to a different address. CLI will accommodate these requests if they are reasonable. If you want to ask for confidential communications, send a written request to the CLI privacy officer at the address shown above. 
Be notified if a breach of confidentiality occurs that involves your PHI. 
ask to see or to get photocopies of your health information. By law, there are a few limited situations in which CLI can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If CLI denies your request, it will send you a written explanation and instructions about how to get an impartial review of its denial if one is legally available. By law, CLI can have one 30-day extension of time for us to give you access or photocopies if we send you a written notice of extension. If you want to review or get photocopies of your health information, send a written request to the CLI privacy officer at the address shown above. 
ask CLI to amend your health information if you think it is incorrect or incomplete. If CLI agrees, it will amend the information within 60 days from date requested. CLI will send the corrected information to persons whom it knows received the wrong information, and others whom you specify. If CLI does not agree, you can write a statement of your position, and CLI will include it with your health information along with any rebuttal it may write. Once your statement of position and/or CLI’s rebuttal is included in your health information, it will send it along whenever it makes a permitted disclosure of your health information. By law, CLI can have one 30-day extension to consider a request for amendment if it notifies you in writing of the extension. If you want to amend your health information, send a written request, which includes your reasons for the amendment, to the CLI privacy officer shown above.  
get a list of the disclosures CLI has made of your health information within the past six years (or a shorter period). By law, the list will not include: disclosures for purposes of treatment, payment of health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. CLI will usually respond to your request within 30 days of receiving it, but by law we can have one 30-day extension of time if CLI notifies you of the extension in writing. If you want a list, send a written request to the CLI privacy officer at the address shown above.  
get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you previously received one. If you want additional paper copies, send a written request to the privacy officer at the address shown above. 
OUR NOTICE OF PRIVACY PRACTICES 
By law, CLI must abide by the terms of this Notice of Privacy Practices until it chooses to change it. CLI reserves the right to change this notice at any time as allowed by law. If CLI changes this Notice, the new privacy practices will apply to your health information that it already has, as well as to such information that CLI may generate in the future. If CLI changes its Notice of Privacy Practices, it will post the new notice in its office, have copies available in its office, and post it on its Web site if applicable. 

COMPLAINTS 
If you think CLI has not properly respected the privacy of your health information, you are free to complain to CLI or the U.S. Department of Health and Human Services Office for Civil Rights. CLI will not retaliate against you if you make a complaint. If you want to complain to CLI, send a written complaint to the CLI privacy officer at the address shown above. If you prefer, you can discuss your complaint in person or by phone. 

FOR MORE INFORMATION 
If you want more information about CLI’s privacy practices, write the CLI privacy officer at the address shown at the beginning of this Notice.

Nondiscrimination & Accessibility for Non English Speaking Patients

Overview: Cataract & Laser Institute standards for nondiscrimination and accessible health care for non-English speaking patients. 

Policy: It is the policy of Cataract & Laser Institute to comply with applicable Federal civil rights laws and not to discriminate. Midwest Eye Consultants does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Cataract & Laser Institute provides:
  • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters.
  • Provides free language services to people whose primary language is not English, such as qualified interpreters.
If you need these services, contact our Central Office at 260-569-9550. If you believe that Midwest Eye Consultants has failed to provide these services or has discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a written grievance with our Compliance Officer at PO Box 549, Wabash, IN 46992.

You can also file a civil rights complaint with the US Department of Health and Human Services for Civil Rights at the address below:

US Department of Health and Human Rights
200 Independence Ave., SW
Room 509F, HHH Building
Washington, DC 20201
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