Effective Date: April 14, 2003
NOTICE OF PRIVACY PRACTICES under
HIPAA (The Health Insurance Portability and Accountability Act of 1996).
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.
If you have any questions about this
notice, please contact the Privacy Officer at
Woodcliff Lake Ophthalmology,
577 Chestnut Ridge Road, Woodcliff Lake, New Jersey 07677
(phone) 201-782-1700 (fax) 201-782-1749
WHO WILL FOLLOW THIS NOTICE:
This notice describes Woodcliff Lake Ophthalmology, LLP's (our "Practice")
practices and that of:
- All physicians and staff of our Practice
- Any student engaged in an externship program through an agreement with our
Practice to do so.
- Our Practice follows the terms of this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. We create a record
of the care and services you receive at our Practice. 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 our Practice.
This notice will tell you about the
ways in which we may use and disclose medical information about you. We also
describe your rights and certain obligations we have regarding the use and disclosure
of medical information.
We are required by law to:
- make sure that medical information that identifies you is kept private;
- give you this notice of our legal duties and privacy practices concerning
medical information about you; and
- follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU.
We use and disclose medical information
in many ways. For each category of uses or disclosures we will explain what
we mean and try to give some examples. Not every use or disclosure in a category
will be listed. However, all of the ways we are permitted to use and disclose
information will fall within one of the categories.
- For Treatment. We may use
medical information about you to provide you with medical treatment or services.
We may disclose medical information about you to doctors, nurses, technicians,
nursing and medical students, or hospital personnel who are involved in taking
care of you. For example, a doctor treating you for a broken leg may need
to know if you have diabetes because diabetes may slow the healing process.
In addition, the doctor may need to tell the dietitian if you have diabetes
so that we can arrange for nutritional counseling. We also may share medical
information about you in order to coordinate the different things you need,
such as prescriptions, lab work and x-rays. We also may disclose medical information
about you to people who may be involved in your medical care such as family
members, clergy, rehabilitation centers, etc.
- For Payment. We may use
and disclose medical information about you so that the treatment and services
you receive at our Practice may be billed for and payment may be collected
from you or on your behalf from an insurance company or a third party. For
example, we may need to give your health plan information about x-rays that
you received at our Practice so your health plan will pay us or reimburse
you for those services. We may also tell your health plan about a treatment
you are going to receive to obtain prior approval or to determine whether
your plan will cover the treatment.
- For Health Care Operations.
We may use and disclose medical information about you for our Practice's operations.
These uses and disclosures are necessary to run our organization and make
sure that all of our patients receive quality care. For example, we may use
medical information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical information
about many our Practice patients to decide what additional services our Practice
should offer, what services are not needed, and whether certain new treatments
are effective. We may also disclose information to doctors, nurses, technicians,
nursing and medical students, and other personnel for review and learning
purposes. We may also combine the medical information we have with medical
information from other similar organizations to compare how we are doing and
see where we can make improvements in the care and services we offer. 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.
We may use and disclose medical information to contact you as a reminder that
you have an appointment for treatment or medical care at our Practice.
- Treatment Alternatives.
We may use and disclose medical information to tell you about or recommend
possible treatment options or alternatives that may be of interest to you.
- Health-Related Benefits and
Services. We may use and disclose medical information to tell you about
health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. We may release
medical 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 and
that you have been seen in our office. In addition, we may disclose medical
information about you to a friend or family member should an emergent situation
arise while you are at our office.
- Research. Under certain
circumstances, we may use and disclose medical information about you for research
purposes. For example, a research project may involve comparing the health
and recovery of all patients who received one medication to those who received
another, for the same condition. All research projects, however, are subject
to a special 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 medical information for research, the project will have
been approved through this research approval process, but we may, however,
disclose medical 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 medical information they review does not leave our organization.
We will 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 our Practice.
- As Required By Law. We
will disclose medical 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 medical 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.
- Organ and Tissue Donation. If
you are an organ donor, we may release medical 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
- Military and Veterans. If you
are a member of the armed forces, we may release medical information about
you as required by military command authorities. We may also release medical
information about foreign military personnel to the appropriate foreign military
- Workers' Compensation. We may
release medical information about you for workers' compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
- Public Health Risks. We may disclose
medical information about you for public health activities. These activities
generally include the following:
· to prevent or control disease, injury or disability;
· to report births and deaths;
· 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. We will only make
this disclosure if you agree or when required or authorized by law.
- Health Oversight Activities. We
may disclose medical 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.
- Lawsuits and Disputes. If you
are involved in a lawsuit or a dispute, we may disclose medical information
about you in response to a court or administrative order. We may also disclose
medical information about you in response to a subpoena, 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 information requested.
- Law Enforcement. We may release
medical information if asked to do so by a law enforcement official:
· In response to a court order, subpoena, warrant, summons or similar
· To identify or locate a suspect, fugitive, material witness, or missing
· About the victim of a crime if, under certain limited circumstances,
we are unable to obtain the person's agreement;
· About a death we believe may be the result of criminal conduct;
· About criminal conduct at the hospital; and
· In emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the person who
committed the crime.
- Coroners, Medical Examiners and
Funeral Directors. We may release medical 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 medical information about
patients to funeral directors as necessary to carry out their duties.
- National Security and Intelligence
Activities. We may release medical information 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 medical 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.
- Inmates. If you are an inmate
of a correctional institution or under the custody of a law enforcement official,
we may release medical 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.
YOUR RIGHTS REGARDING MEDICAL INFORMATION
You have the following rights regarding medical information we maintain about
- Right to Inspect and Copy. You
have the right to inspect and copy medical information that may be used to
make decisions about your care. Usually, this includes medical and billing
records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions
about you, you must submit your request in writing to your our Privacy Officer.
If you request a copy of the information, 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 copy in certain very limited circumstances. If you are denied access to
medical information, you may request, in writing, that the denial be reviewed.
Another licensed health care professional chosen by our Practice will review
your request and the denial. The person conducting the review will not be
the person who previously denied your request. We will comply with the outcome
of the review.
- Right to Amend. If you feel that
medical information we have about you is incorrect or incomplete, you may
ask us to include additional information in your medical record. You have
the right to request an amendment for as long as all of the information, both
old and new, is kept by or for our Practice.
- To request an amendment, your
request must be made in writing and submitted to your our Privacy Officer.
In addition, you must provide a reason that supports your request.
- 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
· Was not created by us, 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 or for our Practice;
· 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 disclosures." This
is a list of the disclosures we made of medical information about you, excluding
disclosures for the purpose of treatment, payment and healthcare operations.
To request this list or accounting of disclosures, you must submit your request
in writing to the Office Manager. Your request must state a time period, which
may not be longer than six years and may not include dates before April 14,
2003. Your request should indicate in what form you want the list (for example,
on paper, electronically). The first list you request within a 12-month period
will be free. For additional lists, we may charge you for the costs of providing
the list. We will notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are incurred.
- Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical 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 medical 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. For example, you could ask that we not
use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you emergency
- To request restrictions, you must
make your request in writing to our Privacy Officer. 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, for example, disclosures to your spouse.
- Right to Request Confidential
Communications. 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.
To request confidential communications, you must make your request in writing
to our Privacy Officer. We will not ask you the reason for your request. We
will accommodate all reasonable requests. Your request must tell us how or
where you wish to be contacted. If you do not tell us how or where you wish
to be contacted, we do not have to follow your request.
- Right to a Paper Copy of This
Notice. You have the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if you have agreed to
receive this notice electronically, you are still entitled to a paper copy
of this notice.
You may obtain a copy of this notice at our web site, www.bergeneye.com.
To obtain a paper copy of this notice, ask any our office staff or our Privacy
Officer or you may write to our Practice at 577 Chestnut Ridge Road, Woodcliff
Lake, New Jersey 07677.
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 in our office. The notice will contain on the first
page, in the top right-hand corner, the effective date. In addition, each time
you are seen for treatment or health care services at our office, we will offer
you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint
with our practice or with the Secretary of the Department of Health and Human
Services at the Office Of Civil Rights, U.S. Department of Health and Human
Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York,
New York 10278. To file a complaint with our Practice, please write to the Privacy
Officer at 577 Chestnut Ridge Road, Woodcliff Lake, New Jersey 07677. All complaints
must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical 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 medical 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 medical 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
Woodcliff Lake Ophthalmology, LLP.