Patient Privacy
Children's Eye Clinic, P.C.
6000 University Avenue, Suite 210
West Des Moines, Iowa 50266

Notice of Privacy Practices
04/01/2003

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Commitment to Your Privacy

We are committed to protecting health information about you. We create a record of the care and services you received from us in order to provide you with quality care and to comply with certain legal requirements. This notice informs you of the ways in which we may use and disclose identifiable health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to maintain the privacy of your health information and to give you this Notice describing our legal duties and privacy practices. We are also required to follow the terms of the Notice currently in effect.

How We May Use and Disclose Health Information About You

We will not use or disclose your health information without your authorization, except in the following situations:

Treatment. We will use and disclose your health information while providing, coordinating or managing your healthcare. We may disclose health information about you to our doctors, nurses, technicians or other personnel who are involved in taking care of you or who are arranging for your care. We also may disclose health information about you to people outside our practice that may be involved in your healthcare, such as, but not limited to, other doctors, pharmacies, surgery centers, hospitals, radiology departments or pathology laboratories to provide a continuity of services that are a part of your care.

Payment. We will use and disclose your medical information about you so that the treatment and services you receive from us may be billed and payment collected from you, an insurance company or a third party. The bill we will send to you or your health plan will include information that identifies you, your diagnosis, the procedure and supplies used. We may also tell your health insurer about a treatment you are going to receive to obtain prior approval or to determine whether your insurer will cover the treatment.

Health Care Operations. We will use and disclose your health information about you for our practice's operations. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use your health information to evaluate our treatment and services or to evaluate our staff's performance while caring for you. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Appointment Reminders. We will use and disclose your health information to contact you and remind you of an appointment with us either by telephone or a reminder card through the mail.

Business Associates. There are some services provided in our organization through contracts with business associates. We will disclose your health information to our business associate so they can perform the job we have asked of them. However, we require the business associate to take precautions to protect your health information. For example, we will forward your information to a contact lens distributor or to an optical laboratory to have your lenses made for your new eyewear.

Notification of Family. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your location or general condition. We may release your health information to a friend or family member who is involved in your health care or to someone who helps pay for your care.

Consent for Medical Photography. We may use or disclose your health information by using photographs or digital images for the purpose of medical documentation and possibly for the purpose of medical education, such as lectures or presentations.

Treatment Alternatives. We may use and disclose your health information to tell you about or recommend possible treatment options, alternatives or services.

Victims of Abuse, Neglect or Domestic Violence. As required by law, we may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect or domestic violence.

Public Health. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse and neglect.

Excuse Slip. We may use and disclose your health information when authorized and necessary to your employer or school to excuse your absence while being treated in our office.

Return to Work or School. We may use or disclose your health information when authorized and necessary to your employer or school while under the care of our office to let them know of your treatment and return date.

Workers Compensation. We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or similar programs.

Court Proceeding. We may disclose your health information in response to requests made during judicial and administrative proceedings, such as court orders or subpoenas.

Health Oversight Activities. We may disclose 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 systems, government programs and compliance with civil rights laws.

Law Enforcement. Under certain circumstances, we may disclose your health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises and crimes in emergencies.

As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (l) 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.

Threats to Public Health or Safety. We may disclose or use heath information when it is our good faith belief, consistent with ethical and legal standards, that it is necessary to prevent or lessen a serious and imminent threat or is necessary to identify or apprehend an individual.

Specialized Government Functions. Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations and for government programs providing public benefits.

Prohibition On Other Uses or Disclosures. We may not make any other use or disclosure of your personal health information without your written authorization. Once given, you may revoke the authorization by writing to our office.

Your Rights Regarding Your Health Information

You have the following rights regarding the health information about you:

Inspection and Copies. You have the right to inspect and obtain a copy of your health information that may be used to make decisions about your care. This includes health and filing records, but does not include psychotherapy notes. To inspect and/or obtain a copy of your health information, you must submit your request in writing to Children's Eye Clinic, P.C. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional will then review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete and you may request an amendment for as long as the information is kept by and for our practice. To request an amendment, your request must be made in writing and submitted to Children's Eye Clinic, P.C. You must provide us with a reason that supports your requests for the amendment. Your failure to submit your request and the reason for the request in writing will result in our denying your request.

We may also deny your request if:

The information was not created by us, unless the person that created the information is no longer available to make the amendment.
The information is not part of the health information kept by or for us.
Is not part of the information you would be permitted to inspect or copy, or is accurate and complete.

Accounting Disclosures. You have the right to request an "accounting of disclosures". This is a list of certain disclosures we have made of your health information. To request this information you must submit your request in writing to Children's Eye Clinic, P.C. Your request must state a time period, no longer that six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free, but we may charge you for additional lists. We will notify you of this cost and you may choose to withdraw or modify your request before charges are incurred.

Right to Request Restrictions. You have the right to request a restriction on our use or disclosure of your health information for treatment, payment or health care operations. You also have the right to request that we limit the health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except in cases of emergency, when otherwise required by law, or when the information is necessary to provide treatment to you. To request restrictions, you must make your request in writing to Children's Eye Clinic, P.C. 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.

Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For instance, you may request that we only contact you at work or by mail. To make such a request, you must write to us at the address below and tell us how or where you wish to be contacted. We will accommodate reasonable requests.

We Reserve the Right to Revise Our Policy Notice. We reserve the right to change this notice. We reserve the right to make the revised notice effective for health 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 in our office. The notice will contain, on the first page, in the top right-hand corner, the effective date.

All requests to restrict use of your health information for treatment, payment and health care operations, to inspect and copy health information, to amend your health information, or to receive an accounting of disclosures of health information must be made in writing to the Privacy Officer at Children's Eye Clinic, P.C.

Other Uses of Health Information. Other uses and disclosure of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. We are unable to "undo" or take back any disclosures we have already made with your permission. Please note, we are required to retain records of your care.

Complaints

If you believe your privacy rights have been violated, you may file a written complaint with the practice or with the Office of Civil Rights, U.S. Department of Health and Human Services. The address for the OCR is listed below. All complaints must be submitted in writing to the attention of the Privacy Officer, Jean Spencer, MD at Children's Eye Clinic, P.C. within 180 days of the suspected violation. The address is at the top of the front page of this notice. You will not be penalized for filing a complaint.

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201