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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that
all medical and dental records and other individually identifiable health information used or disclosed by us in
any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the
patient, significant new rights to understand and control how your health information is used. HIPAA provides
penalties for covered entities that misuse Protected Health Information (PHI).
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to
carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required
by law. It also describes your rights to access and control your protected health information. "Protected health
information" is information about you, including demographic information, that may identify you and that relates
to your past, present or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health Information
Your Protected Health Information may be used and disclosed by your physician, our office staff and others
outside of our office that are involved in your care and treatment for the purpose of providing health care
services to you, to pay your health care bills, to support the operation of the practice, and any other use
required by law.
Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or
manage your health care and any related services. This includes the coordination or management of your health care
with a third party. For example, your protected health information may be provided to a physician to whom you have
been referred to ensure that the health care professional has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for health
care services. For example, obtaining approval for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in
order to support the business activities of your physician’s practice. These activities include, but are not
limited to, quality assessment activities, employee review activities, and conducting or arranging for other
business activities. We may use or disclose, as needed, your protected health information to support the business
activities of this practice. In addition, we may use a sign-in sheet at the registration desk where you will be
asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your
physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact
you to remind you of your appointment. We may call your home and leave a message (either on an answering machine
or with the person answering the phone) to remind you of an upcoming appointment, the need to schedule a new
appointment or to call our office. We may also mail a postcard reminder to your home address. If you would prefer
that we call or contact you at another telephone number or location, please let us know.
We may use or disclose your protected health information in the following situations without your
authorization. These situations include: as Required By Law, Public Health issues required by law, Communicable
Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law
Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and
National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make
disclosures to you and when required by the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements of HIPAA.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent,
Authorization or Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your
physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the
authorization.
Your Rights
The Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, 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 protected health information that is
subject to law that prohibits access to protected health information.
You have the right to request a restriction of your health information. This means you may ask us not to use or
disclose any part of your protected health information for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your protected health information not be disclosed to family
members or friends who may be involved in you care or for notification purposes described in this Notice of
Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction you may request. If your physician believes it is in
your best interest to permit use and disclosure of your protected health information, your protected health
information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at
an alternative location. You have the right to obtain a paper copy of this Notice from us, upon
request, even if you have agreed to accept this Notice alternatively (i.e. electronically).
You may have the right to have your physician amend your protected health information. If we
deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare
a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your
protected health information. We reserve the right to change the terms of this Notice and will inform
you of any changes. You then have the right to object or withdraw as provided in this Notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have
been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint at our
office and main telephone number. We will not retaliate against you for filing a complaint.
This Notice was published and becomes effective on/or before 11/1/2018 12:01 AM.
St. Paul Eye Clinic
Phone: (651) 738-6500 or (800) 727-2279.
Address:
1093 Grand Avenue
St. Paul, Minnesota 55105
