NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PIONEER VALLEY EYE ASSOCIATES, P.C. MAY USE AND DISCLOSE YOUR HEALTH CARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Pioneer Valley Eye Associates, P.C. is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, either created by Pioneer Valley Eye Associates, P.C. or received by Pioneer Valley Eye Associates, P.C. from other health care providers.
We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. Pioneer Valley Eye Associates, P.C. will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information. 1
Pioneer Valley Eye Associates, P.C. reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.
Uses and Disclosures of Your Protected Health Information not Requiring Your Consent
Pioneer Valley Eye Associates, P.C. may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and health care operations. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.
\tTreatment may include:
•\tProviding, coordinating, or managing health care and related services by one or more health care providers;
•\tConsultations between health care providers concerning a patient;
•\tReferrals to other providers for treatment;
•\tReferrals to nursing homes, foster care homes, or health care agencies.
\tFor example, Pioneer Valley Eye Associates, P.C. may determine that you require the services of a specialist. In referring you to another doctor, Pioneer Valley Eye Associates, P.C. may share or transfer your health care information to that doctor.
\tPayment activities may include:
•\tActivities undertaken by Pioneer Valley Eye Associates, P.C. to obtain reimbursement for services provided to you;
•\tDetermining your eligibility for benefits or health insurance coverage;
•\tManaging claims and contacting your insurance company regarding payment;
•\tCollection activities to obtain payment for services provided to you;
•\tReviewing health care services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
•\tObtaining pre-certification pre-authorization of services to be provided to you.
\tFor example, Pioneer Valley Eye Associates, P.C. will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided to you.
\tHealth Care Operations may include:
•\tContacting health care providers and patients with information about treatment alternatives;
•\tConducting quality assessment and improvement activities;
•\tConducting outcomes evaluations and development of clinical guidelines;
•\tProtocol development, case management, or care coordination;
•\tConducting or arranging for medical review, legal services, and auditing functions.
\tFor example, Pioneer Valley Eye Associates, P.C. may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.
Pioneer Valley Eye Associates, P.C. may contact you, by telephone or mail, to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.
We may not disclose your protected health information to family members or friends who may be involved with your treatment or care without your written permission. Health information may be released without written permission to a parent, guardian, or legal custodian or a child; the guardian of an incompetent adult; the health care agent designated in an incapacitated patient’s health care power of attorney; or the personal representative or spouse of a deceased patient.
There are additional situations when Pioneer Valley Eye Associates, P.C. is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:
•\tAs permitted or required by law.\t
In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime.
Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.
•\tFor public health activities.
We may release health care records, with the exception of treatment records, to certain government agencies or public health authority authorized by law, upon receipt of written request from that agency. We are required to report positive HIV test results to the state epidemiologist. We may also disclose HIV rest results to other providers or persons when there has been or will be risk of exposure. We may report to the state epidemiologist the name of any person known to have been significantly exposed to a patient who tests positive for HIV. We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV test results in connection with the reporting or prosecution of alleged abuse or neglect. We may release health care records, including treatment records and HIV test results, to the Food and Drug Administration when required by federal law. We may disclose health care records, except for HIV test results, for the purpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm. Records may be released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.
•\tFor health oversight activities.
We may disclose health care records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification. HIV test results may not be released to federal or state governmental agencies, without written permission, except to the state epidemiologist for surveillance, investigation, or to control communicable diseases.
•\tJudicial and Administrative Proceedings.
Patient health care records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all health care records except for HIV test results.
•\tFor activities related to death.
We may disclose patient health care records, except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death. HIV test results may be disclosed under certain circumstances.
Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
•\tTo avoid a serious threat to health or safety.
We may report a patient’s name and other relevant data to the Department of Transportation if it is believed that the patient’s vision or physical or mental condition affects the patient’s ability to exercise reasonable or ordinary control over a motor vehicle. Health care information, including treatment records and HIV test results, may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.
•\tFor workers’ compensation.
We may disclose your health information to the extent such records are reasonably related to any injury for which workers’ compensation is claimed.
Pioneer Valley Eye Associates, P.C. will not make any other use or disclosure of your protected health information without your written authorization. You may revoke such authorization at any time, except to the extent that Pioneer Valley Eye Associates, P.C. has taken action in reliance thereon. Any revocation must be in writing.
Your Rights Regarding Your Protected Health Information
You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by Pioneer Valley Eye Associates, P.C. to carry out treatment, payment, or health care operations. You must request such a restriction in writing. We are not required to agree to your request, but if we do agree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to health care providers treating you. Also, a restriction would not apply when we are required by law to disclose certain health care information.
You have the right to review and/or obtain a copy of your health care records, with the exception of psychotherapy notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. The Pioneer Valley Eye Associates, P.C. may deny an access under other circumstances, in which you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.
You may request that Pioneer Valley Eye Associates, P.C. send protected health information, including billing information to you by alternative means or to alternative locations. You may also request that Pioneer Valley Eye Associates, P.C. not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.
You have the right to request that Pioneer Valley Eye Associates, P.C. amend portions of your health care records, as long as such information is maintained by us. You must submit this request in writing, and under certain circumstances the request may be denied.
You may request to receive an accounting of the disclosures of your protected health information made by Pioneer Valley Eye Associates, P.C. for the six years prior to the date of request, beginning with disclosures made after April 14, 2003. We are not required, however, to record disclosures we make pursuant to a signed consent or authorization.
You may request and receive a paper copy of this Notice, if you had previously received or agreed to receive the Notice electronically.
Any person or patient may file a complaint with Pioneer Valley Eye Associates, P.C. and/or the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with Pioneer Valley Eye Associates, P.C., please contact the Privacy Officer at the following:
\tPioneer Valley Eye Associates, P.C.
\t2 Hospital Drive, Suite 201
\tHolyoke, MA 01040
\tPhone: 413-536-8670\tFax: 413-534-0597
It is the policy of Pioneer Valley Eye Associates, P.C. that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual noncompliance or violation of the privacy standards.
This Notice of Privacy Practices is effective April 14, 2003.
PIONEER VALLEY ASSOCIATES, P.C.\t\t\tNotice of Privacy Practices
Effective April 14, 2003
1 This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R. 164.520.