Privacy Notice
Notice of Privacy Practices
Kelsea D. Naylor O.D.
113 N. Lisbon St. Carrollton, OH 44615
330-627-2430
Fax: 330-627-5681
Contact person: Dr. Kelsea D. Naylor
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 Is Effective As of April 14, 2003
Our office is required to maintain the privacy of your Protected Health Information (?PHI?) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic 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. This Notice of Privacy Practices (?Notice?) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.
Our office is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request we will provide a revised Notice to you.
Examples of How We May Use and Disclose PHI: The following categories describe and provide examples of different ways that we use and disclose PHI about you.
We will use PHI for treatment.
We will use PHI for payment. Example: We will contact your insurer to determine whether it will pay for your professional care and materials. We will bill you or a third party payer for the cost of professional services and any materials dispensed to you. The information on or accompanying the bill may include information that identifies you.
We will use PHI for health care operations. Example: Our office may use information in your health record to monitor the performance of the doctors and staff members providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the health-care services we provide.
We are likely to use or disclose PHI for the following purposes:
Business associates: There are some services provided by us through contracts with business associates. When the services are contracted for, we may disclose PHI about you to our business associates so that they can perform the job we have asked them to do and bill you or your third party payer for the services rendered. To protect PHI about you, we require the business associate to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care:
Health professionals such as an optometrist, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person?s involvement in your care or payment related to your care.
Personal Communications: We may contact you to provide reminders or information about treatment alternatives or other health-related benefits and services that may be of interest you.
Food and Drug Administration (FDA): We may disclose to the FDA or its agents PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Workers? Compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to Workers? Compensation or other similar programs established by law.
Other Health Care Providers: We may disclose PHI about you for treatment or repayment activities of another health care provider. We may also disclose PHI about you to another health care provider for the health care operation?s activities (quality assessments, competence, and performance reviews as well as others) of that health care provider providing they too have a relationship with you. We may also disclose PHI about you to such a health care provider for the purpose of health-care fraud and abuse detection or compliance.
Public Health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena.
As required by law: We must disclose PHI about you when required to do so by law.
Health Oversight Activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, a discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI.
We are permitted to use or disclose PHI about you for the following purposes:
Research: We may disclose PHI about you to researchers when their research has been approved by an institution review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors: We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.
Organ or Tissue Procurement Organizations: Consistent with applicable law, we may disclose PHI about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Correctional Institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents, PHI necessary for your health and the health and safety of others.
To Avert a Serious Threat to Health or Safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence. We will only disclose this type of information to the extent required by law.
Other Uses and Disclosures of PHI
This office will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at anytime. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.
Your Health Information Rights
You have the following rights with respect to PHI about you:
Obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, please request one from our office.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to our office.
Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as the office maintains the PHI. The "designated record set" usually will include treatment and billing records. To inspect or copy PHI about you, you must send a written request to our office. Forms are available for this request. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. We may charge you a fee for the cost of copying, mailing and other supplies that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.
Request an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the office. Forms for this are available. It is not necessary to use this form but it may aid you in providing adequate information for us to process your request. In addition, you must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give you a rebuttal to your statement.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations. To request an accounting, you must submit your request in writing to our office. Forms are available at our office. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. Your request must specify the time, but may not be longer than six years. The first accounting you request within a twelve-month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify you request at that time.
Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit your request in writing to our office. Forms for this are available. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.
For More Information or to Report a Problem
If you have questions or would like additional information about our office?s privacy practices, you may contact us by phone or email. If you believe your privacy rights have been violated, you can file a complaint with our office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Kelsea D. Naylor O.D.
113 N. Lisbon St. Carrollton, OH 44615
330-627-2430
Fax: 330-627-5681
Contact person: Dr. Kelsea D. Naylor
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 Is Effective As of April 14, 2003
Our office is required to maintain the privacy of your Protected Health Information (?PHI?) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic 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. This Notice of Privacy Practices (?Notice?) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.
Our office is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request we will provide a revised Notice to you.
Examples of How We May Use and Disclose PHI: The following categories describe and provide examples of different ways that we use and disclose PHI about you.
We will use PHI for treatment.
We will use PHI for payment. Example: We will contact your insurer to determine whether it will pay for your professional care and materials. We will bill you or a third party payer for the cost of professional services and any materials dispensed to you. The information on or accompanying the bill may include information that identifies you.
We will use PHI for health care operations. Example: Our office may use information in your health record to monitor the performance of the doctors and staff members providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the health-care services we provide.
We are likely to use or disclose PHI for the following purposes:
Business associates: There are some services provided by us through contracts with business associates. When the services are contracted for, we may disclose PHI about you to our business associates so that they can perform the job we have asked them to do and bill you or your third party payer for the services rendered. To protect PHI about you, we require the business associate to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care:
Health professionals such as an optometrist, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person?s involvement in your care or payment related to your care.
Personal Communications: We may contact you to provide reminders or information about treatment alternatives or other health-related benefits and services that may be of interest you.
Food and Drug Administration (FDA): We may disclose to the FDA or its agents PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Workers? Compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to Workers? Compensation or other similar programs established by law.
Other Health Care Providers: We may disclose PHI about you for treatment or repayment activities of another health care provider. We may also disclose PHI about you to another health care provider for the health care operation?s activities (quality assessments, competence, and performance reviews as well as others) of that health care provider providing they too have a relationship with you. We may also disclose PHI about you to such a health care provider for the purpose of health-care fraud and abuse detection or compliance.
Public Health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena.
As required by law: We must disclose PHI about you when required to do so by law.
Health Oversight Activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, a discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI.
We are permitted to use or disclose PHI about you for the following purposes:
Research: We may disclose PHI about you to researchers when their research has been approved by an institution review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors: We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.
Organ or Tissue Procurement Organizations: Consistent with applicable law, we may disclose PHI about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Correctional Institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents, PHI necessary for your health and the health and safety of others.
To Avert a Serious Threat to Health or Safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence. We will only disclose this type of information to the extent required by law.
Other Uses and Disclosures of PHI
This office will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at anytime. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.
Your Health Information Rights
You have the following rights with respect to PHI about you:
Obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, please request one from our office.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to our office.
Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as the office maintains the PHI. The "designated record set" usually will include treatment and billing records. To inspect or copy PHI about you, you must send a written request to our office. Forms are available for this request. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. We may charge you a fee for the cost of copying, mailing and other supplies that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.
Request an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the office. Forms for this are available. It is not necessary to use this form but it may aid you in providing adequate information for us to process your request. In addition, you must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give you a rebuttal to your statement.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations. To request an accounting, you must submit your request in writing to our office. Forms are available at our office. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. Your request must specify the time, but may not be longer than six years. The first accounting you request within a twelve-month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify you request at that time.
Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit your request in writing to our office. Forms for this are available. It is not necessary to use this form but it may aid you in providing adequate information to us to process your request. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.
For More Information or to Report a Problem
If you have questions or would like additional information about our office?s privacy practices, you may contact us by phone or email. If you believe your privacy rights have been violated, you can file a complaint with our office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
