This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully!
Board Approved 3/13/03
Wolfe Eye Clinic, P.C. and Wolfe Clinic Eye Centers, L.L.C. shall be referred to as Wolfe Clinic in this document.
This document describes the type of information we gather about you, with whom that information may be shared and the safeguards we have in place to protect it. You have the right to the confidentiality of your medical information and the right to approve or refuse the release of specific information except when the release is required by law. If the practices described in this document meet your expectations, there is nothing you need to do. If you prefer that we not share information we may honor your written request in certain circumstances described in the following paragraphs. If you have any questions about this notice, please contact our Privacy Office at the address listed below.
ABOUT THIS NOTICE
We are required by law to maintain the privacy of protected health information and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights and we have certain legal obligations regarding the privacy of your protected health information. This Notice explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.
Protected Health Information (PHI) is information, whether oral or recorded in any form, that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for such health care this is created or received by Wolfe Clinic. Demographic information collected is a subset of PHI and is thus included in this definition.
WHO WILL FOLLOW THIS NOTICE
This notice describes Wolfe Clinic practices regarding the use of your protected health information and that of:
- Any health care professional authorized to enter information into our clinic chart or medical record
- All departments and areas of the clinic you may visit
- All employees, staff, and other personnel who may need access to your information
- All entities, sites, and locations of Wolfe Clinic follow the terms of this notice. In addition, these entities, sites and locations may share protected health information with each other for treatment, payment, or health care purposes described in this notice.
OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION
We understand that medical information about you and your health is personal. Protecting medical information about you is important. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Wolfe Clinic, whether made by health care professionals or other personnel.
This notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information.
We are required by law to:
- keep medical information that identifies you private;
- give you this notice of our legal duties and privacy practices with respect to protected health information about you; and
- follow the terms of this notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that we may use and disclose protected health information. For each category of uses or disclosures we will try to give some examples. Not every use or disclosure in a category will be listed.
We may use protected health information about you to provide you with medical treatment and services. We may disclose protected health information about you to doctors, nurses, technicians, training doctors, or other health care professionals who are involved in taking care of you. For example, a doctor treating you for visual loss might detect a potential neurological problem that may require the patient’s family medical doctor to order additional testing. Different health care professionals also may share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside Wolfe Clinic who may be involved in your medical care or that provide services that are a part of your care.
We may use and disclose protected health information about you so that treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. For example, your insurance may need to know about surgery you received so they will pay us or reimburse you for the surgery. We may also use and disclose protected health information about you to obtain prior approval or to determine whether your insurance will cover the treatment.
FOR HEALTH CARE PURPOSES
We may use and disclose protected health information about you for health care purposes. This is necessary to make sure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, training doctors, medical students, and other clinic personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
APPOINTMENT REMINDERS / TREATMENT ALTERNATIVES / HEALTH RELATED BENEFITS AND SERVICES
We may contact you as a reminder that you have an appointment for treatment or medical care or to request that you contact Wolfe Clinic to make an appointment for treatment or medical care. We may contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
We may leave a message on your answering machine or with a family member or others involved in your health care. Such messages may relate to appointment information, test results, or follow-up information about your treatment at Wolfe Clinic. You may request that we not leave messages of this type.
We may contact you to provide you information about treatment options or alternatives that may be of interest to you.
HEALTH-RELATED BENEFITS AND SERVICES
We may contact you to tell you about health-related benefits and services that may be of interest to you.
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE
We may release protected health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose protected health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
We may disclose protected health information of minor children to their parents or guardians unless such disclosure is prohibited by law.
We may contact you regarding health-related benefits and services we feel may be of interest to you. You may decline to receive information of this type.
We may contact you regarding the Wolfe Clinic Foundation, a non-profit organization that supports eye care research as well as eye care efforts to individuals in need. You may decline to receive information of this type.
Under certain circumstances, we may use and disclose protected health information about you for research purposes. For example, a research project may involve comparing the post-operative vision of patients who received one type of intraocular lens with the post-operative vision of patients who received another type of intraocular lens. All research projects, however, are subject to a special Wolfe Clinic approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose protected health information for research, the project will have been approved through this research approval process, but we may, however, disclose protected health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the protected health information they review does not leave the clinic. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at Wolfe Clinic.
AS REQUIRED BY LAW
We will disclose protected health information about you when required to do so by federal, state, or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
We may use and disclose protected health information 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. Any disclosure, however, would only be to someone able to help prevent the threat.
We may disclose protected health information to our business associates who perform functions on behalf or provide us with services if the protected health information is necessary for those functions or services. For example, we may use another company to do billing, transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your protected health information.
ORGAN AND TISSUE DONATION
If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
MILITARY AND VETERANS
If you are a member of the armed forces, we may release protected health information about you as required by military command authorities.
We may release protected health information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
HEALTH OVERSIGHT ACTIVITIES
We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
PUBLIC HEALTH RISKS
We may disclose protected health information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability
- to report child abuse or neglect
- to report reactions to medications or problems with products
- to notify people of recalls of products they may be using
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence
LAWSUITS AND DISPUTES
We may disclose protected health information about you in response to a subpoena, discovery request, or other lawful order from a court.
We may release protected health information if asked to do so by a law enforcement official as part of law enforcement activities; in investigations of criminal conduct or of victims of crime; in response to court orders; in emergency situations; or when required to do so by law.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may release protected health information 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 release protected health information about patients to funeral directors as necessary to carry out their duties.
PROTECTIVE SERVICES FOR THE PRESIDENT, NATIONAL SECURITY AND INTELLIGENCE AGENCIES
We may release protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
DATA BREACH NOTIFICATION PURPOSES
We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure or your health information.
We may use or disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care or notify family or friends of your location in the event of a disaster.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
You have the following rights regarding protected health information we maintain about you:
RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy of protected health information that may be used to make decisions about your care. This usually includes medical and billing records. Such a request must be made in writing and submitted to our Privacy Officer at the address listed below. We may charge a fee for the cost of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy your protected health information in very limited circumstances. If your request is denied, you may request that the denial be reviewed.
RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS
If your protected health information is maintained in an electronic format (known as an electronic medical record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your protected health information in the form or format you requested, if it is readily producible in such form or format. If the protected health information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format, or if you do not want this form or format, in a readable hard copy form. We may charge you a reasonable cost-based fee for the labor associated with transmitting the electronic medical record.
RIGHT TO AMEND
If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is kept. The request must provide the reason that supports your request and be submitted in writing to our Privacy Officer at the address listed below.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by Wolfe Clinic, unless the person or entity that created the information is no longer available to make the amendment;
- is not part of the medical information kept by Wolfe Eye Clinic;
- is not part of the information which you would be permitted to inspect and copy; or
- is accurate and complete.
RIGHT TO AN ACCOUNTING OF DISCLOSURES
You have the right to request an “accounting of certain disclosures.” This is a list of the disclosures we made of your protected health information other than for treatment, payment, or health care purposes as described in this Privacy Notice.
To request this list, you must submit your request in writing to our Privacy Officer at the address listed below. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. We may charge a fee for the cost of copying, mailing or other tasks associated with your request.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” in full.
If we do agree to your request, we will comply unless the information is needed to provide you emergency treatment.
To request restrictions, you must submit your request in writing to our Privacy Officer at the address listed below. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.
If you paid in full (or in other words, you have requested that we not bill your health plan) for a specific item or service, you have the right to ask that your protected health information with respect to that item or service not be disclosed to a health care plan for purposes of payment and we will honor that request.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
For confidential communication, you must submit your request in writing to our Privacy Officer at the address listed below and specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice at any time. Even if you have agreed that you do not need a copy now, or have viewed this electronically, you are still entitled to a paper copy. Please request one in writing from our Privacy Officer at the address listed below.
RIGHT TO GET NOTICE OF A BREACH
You have the right to be notified upon a breach of any of your unsecured protected health information.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date. A copy of our current Notice is posted in our office and on our website.
OTHER USES AND DISCLOSURES REQUIRING WRITTEN AUTHORIZATION
The following uses and disclosures of your protected health information will be made only with your written authorization:
- Uses and disclosures of protected health information for marketing purposes.
- Disclosures that constitute a sale of your protected health information.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
If you believe your privacy rights have been violated, you may file a complaint with Wolfe Clinic, with the Secretary of the Department of Health and Human Services, or the Office of Civil Rights. To file a complaint with Wolfe Clinic, contact our Privacy Officer at the address and phone number listed below. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
309 E. Church Street
Marshalltown, IA 50158
Phone: (800) 542-7956
Fax: (641) 753-8717