Draft — effective date to be set by the practice
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 applies to 1234 Ortho-K Vision Care and Dr. Paul T. Woo, Optometrist. It covers all of our offices, including our Walnut office when it opens. Many of our patients are children. When this notice says “you,” it also means a parent or guardian acting for a child who is our patient.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your medical records
- You can ask to see or get a copy of your medical records and other health information we have about you. Ask us how to do this.
- We will give you a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical records
- You can ask us to correct health information about you that you think is wrong or incomplete. Ask us how to do this.
- We may say “no” to your request, but we will tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, by home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out of pocket in full, you can ask us not to share that information with your health insurer for payment or our operations. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years before the date you ask, who we shared it with, and why.
- We will include all disclosures except those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
- We will provide one list a year for free. We may charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will give you a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney, or if someone is your legal guardian, that person can use your rights and make choices about your health information.
- Parents and legal guardians can usually act for their minor children. In some cases, California law lets minors control certain health information themselves.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- If you feel we have violated your rights, you can complain to us by contacting our Privacy Officer at 1234 S. Garfield Ave. #105, Alhambra, CA 91801, or by calling (626) 282-5388.
- You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit https://www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and the choice to tell us to:
- Share information with your family, close friends, or others involved in your care.
- Share information in a disaster relief situation.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
- Marketing purposes.
- Sale of your information.
In other words, we will not use or share your information for marketing, or sell it, without your written permission.
Our Uses and Disclosures
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you. Example: Dr. Woo shares your child’s eye exam results with your child’s pediatrician.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use your health information to manage your treatment and to send you appointment reminders.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your vision or health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
- Help with public health and safety issues: for example, preventing disease, helping with product recalls, reporting adverse reactions to medicines, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
- Do research: we can use or share your information for health research.
- Comply with the law: we will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
- Respond to organ and tissue donation requests: we can share health information about you with organ procurement organizations.
- Work with a medical examiner or funeral director: we can share health information with a coroner, medical examiner, or funeral director when an individual dies.
- Address workers’ compensation, law enforcement, and other government requests: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services.
- Respond to lawsuits and legal actions: we can share health information about you in response to a court or administrative order, or in response to a subpoena.
California Law
California law may give you additional protections. For example, the California Confidentiality of Medical Information Act limits how we may share your medical information. When a California law protects your information more than federal law does, we will follow the California law.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information, see https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office, and on our website.
Contact Us
If you have questions about this notice or want to use any of your rights, contact our Privacy Officer: 1234 Ortho-K Vision Care, 1234 S. Garfield Ave. #105, Alhambra, CA 91801. Phone: (626) 282-5388. Toll-free: (800) 991-8881.
This notice covers the health information in your medical records. Our website privacy policy explains how we handle the information you send us through this website, such as a booking request.
Effective Date
This notice is effective as of: Draft — effective date to be set by the practice.