Teagle
Optometry - Notice Of Privacy Practices
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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 privacy of
your medical information is important to us.
Overview:
The law requires us to keep your protected health
information (“PHI”) private in accordance with this
Notice of Privacy Practices (“Notice”), as long as this
Notice remains in effect. We are also required to
provide you with a paper copy of this Notice, which
contains our privacy practices, our legal duties, and
your rights concerning your PHI.
From time to time, we may revise our privacy practices
and the terms of our Notice at any time, as permitted or
required by applicable law. Such revisions to our
privacy practices and our Notice may be retroactive. Our
Notice will be updated and made available to our
patients prior to any significant revisions of our
privacy practices and policies.
Organizations Covered by this Notice (Optional
language for Organized Health Care Arrangements)
This notice contains the privacy practices for (types of
organizations) listed below, with the (types of
facilities) sites they maintain for delivery of health
care products and services. Each of these organizations
participates in an organized participates in an
organized heath care arrangement and may use and
disclose your PHI among themselves as they shall deem
appropriate for your treatment, payment or health care
operations.
Our Privacy Practices
Use and Disclosure. We may use or disclose your PHI for
treatment, payment, or health care operations. For your
convenience, we have provided the following examples of
such potential uses or disclosures:
· Treatment: Your PHI may be used by or disclosed to any
physicians or other health care providers involved with
the medical services provided to you.
· Payment: Your PHI may be used or disclosed in order to
collect payment for the medical services provided to
you.
· Health Care Operations: Your PHI may be used or
disclosed as part of our internal health care
operations. Such health care operations may include,
among other things, quality of care audits of our staff
and affiliates, conducting training programs,
accreditation, certification, licensing, or
credentialing activities.
Authorizations. We will not use or
disclose your medical information for any reason except
those described in this Notice unless you provide us
with a written authorization to do so. We may request
such an authorization to use or disclose your PHI for
any purpose, but you are not required to give us such
authorization as a condition of your treatment. You may
revoke any written authorization from you by you in
writing at any time, but such revocation will not affect
any prior authorized uses or disclosures.
Patient Access. We will provide you with
access to your PHI, as described below in the Individual
Rights section of this Notice. With your permission, or
in some emergencies, we may disclose your PHI to your
family members, friends, or other people to aid in your
treatment or the collection of payment. A disclosure of
your PHI may also be made if we determine it is
reasonably necessary or in your best interests for such
purposes as allowing a person acting on your behalf to
receive filled prescriptions, medical supplies, X rays,
etc.
Facility Directories. (Optional Language
for Inpatient facilities) Our facility directory may
list the following information about you: (1) your name,
(2) your location in our facility, (3) your general
condition without reference to specific medical
information, e.g., stable, serious, fair, etc., and (4)
your religious affiliation, if any. Our facility
directory information may be disclosed to clergymen and,
except for religious affiliation, to other people. You
may restrict or prohibit the release of the above
information.
Locating Responsible Parties. Your PHI may
be disclosed in order to locate, identify or notify a
family member, your personal representative, or other
person responsible for your care. If we determine in our
reasonable professional judgment that you are capable of
doing so, you will be given the opportunity to consent
to or to prohibit or restrict the extent or recipients
of such disclosure. If we determine that you are unable
to provide such consent, we will limit the PHI disclosed
to the minimum necessary.
Disasters. We may use or disclose your PHI
to any public or private entity authorized by law or by
its charter to assist in disaster relief efforts.
Required by Law. We may use or disclose
your medical information when we are required to do so
by law. For example, your PHI may be released when
required by privacy laws, workers’ compensation or
similar laws, public health laws, court or
administrative orders, subpoenas, certain discovery
requests, or other laws, regulations or legal processes.
Under certain circumstances, we make limited disclosures
of PHI directly to law enforcement officials or
correctional institutions regarding an inmate, lawful
detainee, suspect, fugitive, material witness, missing
person, or a victim or suspected victim of abuse,
neglect, domestic violence or other crimes. We may
disclose your PHI to the extent reasonably necessary to
avert a serious threat to your health or safety or the
health or safety of others. We may disclose your PHI
when necessary to assist law enforcement officials to
capture a third party who has admitted to a crime
against you or who has escaped from lawful custody.
Deceased Persons. After your death, we may
disclose your PHI to a coroner, medical examiner,
funeral director, or organ procurement organization in
limited circumstances.
Research. Your PHI may also be used or
disclosed for research purposes only in those limited
circumstances not requiring your written authorization,
such as those which have been approved by an
institutional review board that has established
procedures for ensuring the privacy of your PHI.
Military and National Security. We may
disclose to military authorities the medical information
of Armed Forces personnel under certain circumstances.
When required by law, we may disclose your PHI for
intelligence, counterintelligence, and other national
security activities.
Your Individual Rights
Access and Copies. In most cases, you have
the right to review or to purchase copies of your PHI by
requesting access or copies in writing to our Privacy
Officer. Please contact our Privacy Officer regarding
our copying fees.
Disclosure Accounting. You have the right
to receive an accounting of the instances, if any, in
which your PHI was disclosed for purposes other than
those described in the following sections above: Use and
Disclosures, Facility Directories, Patient Access, and
Locating Responsible Parties. For each 12-month period,
you have the right to receive one free copy of an
accounting certain details surrounding such disclosures
that occurred after April 13, 2003. If you request a
disclosure accounting more than once in a 12-month
period, we will charge you a reasonable, cost-based fee
for each additional request. Please contact our Privacy
Officer regarding these fees.
Additional Restrictions. You have the
right to request that we place additional restrictions
on our use or disclosure of your PHI, but we are not
required to honor such a request. We will be bound by
such restrictions only if we agree to do so in writing
signed by our Privacy Officer.
Alternate Communications. You have the
right to request that we communicate with you about your
PHI by alternative means or in alternative locations. We
will accommodate any reasonable request if it specifies
in writing the alternative means or location, and
provides a satisfactory explanation of how future
payments will be handled.
Amendments to PHI. You have the right to request
that we amend your PHI. Any such request must be in
writing and contain a detailed explanation for the
requested amendment. Under certain circumstances, we may
deny your request but will provide you a written
explanation of the denial. You have the right to send us
a statement of disagreement to which we may prepare a
rebuttal, a copy of which will be provided to you at no
cost. Please contact our Privacy Officer with any
further questions about amending your medical record.
Complaints
If you believe we have violated your privacy rights, you
may complain to us or to the Secretary of the U.S.
Department of Health and Human Services. You may file a
complaint with us by notifying our Privacy Officer.
We support your right to protect the privacy of your
medical information. We will not retaliate in any way if
you choose to file a complaint with us or with the U.S.
Department of Health and Human Services.
Contact Us
Dr. Donald Teagle
1321 Glendale Galleria
Glendale, CA 91210
818-956-0873 Fax: 818-956-1307 |
