Privacy

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At Great Lakes Eye Surgery Center, we are committed to treating and using protected health information about you responsibly. This Notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 and applies to all protected health information as defined by federal regulations.

UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATION Each time you visit Great Lakes Eye Surgery Center, a record of your visit is made. Typically, this record contains information about your visit including your examination, diagnosis, test results, treatment as well as other pertinent healthcare data. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment.Means of communication with other health professionals involved in your care.Legal document outlining and describing the care you received.Tools that you or another payer (your insurance co) will use to verify that services billed were actually provided.An education tool for medical health providers.A source for medical research.Basis for public health officials who might use this information to assess and/or improve state as well as national healthcare standards.A tool that we can reference to ensure the highest quality of care and patient satisfaction. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, determine what entities have access to your health information, and make an informed decision when authorizing the disclosure of this information to other individuals.

YOUR RIGHTS You have certain rights under the federal privacy standards. These include: The right to request restrictions on the use and disclosure of your protected health information.The right to receive confidential communications concerning your medical condition and treatment.The right to inspect and copy your protected health information.The right to amend or submit corrections to your protected health information.The right to receive an accounting of how and to whom your protected health information has been disclosed.The right to receive a printed copy of this notice.

OUR RESPONSIBILITIES Great Lakes Eye Surgery Center is required to: Maintain the privacy of your health information.Provide you with this Notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.Abide by the terms of this notice.Notify you if we are unable to agree to a requested restriction.Accommodate reasonable requests you may have regarding communication of health information via alternative means and locations. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to procedures included in the authorization.

HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATION  We will use your health information for treatment.Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example: results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. We will use your information for payment.Your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated in order to pay for the service rendered to you. We will use your information for regular health operations.Your health information may be used as necessary to support the day-to-day activities and management of Great Lakes Eye Surgery Center. For example: Information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Business Associates. In some instances, we have contracted separate entities to provide services for us. These “associates” require your health information in order to accomplish the tasks that we ask them to provide. Some examples of these “business associates” might be a billing service, collection agency, answering services and computer software/hardware provider. Communication with family.Due to the nature of our field, we will use our best judgment when disclosing health information to a family member, other relatives, or any other person that is involved in your care or that you have authorized to receive this information. Please inform the practice when you do not wish a family member or other individual to have authorization to receive your information.

Research/Teaching/Training. We may use your information for the purpose of research, teaching, and training. Healthcare Oversight.Federal law requires us to release your information to an appropriate health oversight agency, public health authority or attorney, or other federal/state appointee if there are circumstances that require us to do so. Public health reporting.Your health information may be disclosed to public health agencies as required by law. Law enforcement.Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Appointment reminders.   The practice may use your information to remind you about upcoming appointments. Typically, appointment reminders are sent by mail via postcard, or a brief message may be left on your answering machine. If you don’t approve of these methods, or, if you prefer alternative methods please inform the practice.

Other uses and disclosures.     Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.Office visit.We will verify your name, address, date of birth, and current health insurance carrier when you check into our office. Please see our full version of our Privacy Practices displayed in our reception area for more detail.

If you believe that your privacy rights have been violated, please contact the aforementioned practice Privacy Official, or, you may file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice’s Privacy Official or with the Office for Civil Rights.

FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have complaints, questions, or would like additional information regarding this Notice or the privacy practices of Great Lakes Eye surgery Center, please contact:

OFFICE FOR CIVIL RIGHTS

Department of Health and Human Services

200 Independence Avenue, S.W. Room 509F

HHH Building Washington D.C. 20201

PRIVACY OFFICERS

Dr. Farhad Shokoohi, MD, Medical Director

Rae A. Eitel, RN CNOR, Administrator