Privacy Notice
NOTICE OF PRIVACY PRACTICES
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.
Effective: April 14, 2003
Georgia Optometry Group is required by law to protect the privacy of your health information. We are also required to provide you this notice which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.
The terms "information" or "health information" in this notice include any personal information that is created or received by us or your health plan that relates to your physical or mental health or condition, the provision of health care to you, or the payment for such health care.
We reserve the right to change our privacy practices. If we do, we will provide the revised notice to you within 60 days by posting it on our Web site.
HOW WE USE OR DISCLOSE INFORMATION
We must use and disclose your health information:
-To you or someone who has the legal right to act for you (your personal representative)
-To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected and
-Where required by law.
We have the right to use and disclose health information to receive payment for your vision care and operate our business. For example, we may use your health information:
-To Obtain Payment of claims for vision care services you receive from us.
-For Health Care Operations. We may use or disclose vision information, as necessary to manage your vision care coverage with your insurance company.
We may use or disclose your health information for the following purposes under limited circumstances:
-To Persons Involved With Your Care We may use or disclose your health information to a person involved in your care, such as a family member, when you are incapacitated or in an emergency, or when permitted by law another health care provider.
-For Public Health Activities such as reporting disease outbreaks.
-For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities, including a social service or protective service agency.
-For Health Oversight Activities such as governmental audits and fraud and abuse investigations.
-For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
-For Law Enforcement Purposes such as providing limited information to locate a missing person.
-To Avoid a Serious Threat to Health or Safety by, for example, disclosing information to public health agencies.
-For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
-For Workers Compensation including disclosures required by state workers compensation laws of job-related injuries.
-Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
If none of the above reasons applies, then we must get your written authorization to use or disclose your health information. If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is our intent to meet the requirements of the more stringent law. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization, except if we have already acted based on your authorization. Write us to revoke an authorization, refer to "Exercising Your Rights" of this notice for guidance.
HIGHLY CONFIDENTIAL INFORMATION
Federal and Georgia laws require special privacy protections for highly confidential information about you. "Highly confidential information" may include confidential information about alcohol and drug abuse as well as the following types of information:
1. HIV/AIDS
2. Mental health
3. Genetic tests
4. Alcohol and drug abuse
5. Sexually transmitted diseases and reproductive health information and
6. Child or adult abuse or neglect, including sexual assault.
WHAT ARE YOUR RIGHTS
The following are your rights with respect to your health information.
-You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to all restrictions requested.
-You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).
-You have the right to see and obtain a copy of health information that may be used to make decisions about you such as claims and vision management records. You also may receive a summary of this your vision information, such as prescriptions. You must make a written request to inspect and copy your health information at our office(s). You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete. If we deny your request, you may have a statement of your disagreement added to your health information.
-You have the right to receive an accounting of disclosures of your information made by us up to six years prior to your request. This accounting will not include disclosures of information: (i) made prior to April 14, 2003 (ii) for treatment, payment, and vision care operations purposes (iii) to you or pursuant to your authorization and (iv) to correctional institutions or law enforcement officials and (v) other disclosures that federal law does not require us to provide an accounting.
-You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. You are entitled to a paper copy of this notice, if requested, or you may print one from this web site.
EXERCISING YOUR RIGHTS
Contacting your Vision Provider. If you have any questions about this notice or want to exercise any of your rights, please contact Georgia Optometry Group at:770-392-0154, fax 770-698-0612 or by mail:
Attn: HIPAA Compliance
Georgia Optometry Group
Suite E
4651 Chamblee Dunwoody Rd
Atlanta, GA 30338
Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:
Attn: HIPAA Compliance
Georgia Optometry Group
Suite E
4651 Chamblee Dunwoody Rd
Atlanta, GA 30338
You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing privacy rights violation complaint.
FINANCIAL INFORMATION PRIVACY NOTICE
Effective: April 14, 2003
We are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, "personal financial information" means information, other than health information, about you that is not generally publicly available and is collected from the individual or is obtained in connection with providing vision care for you.
We collect personal financial information about you from the following sources:
-Payments you make for your services and materials
-Information we receive from you on applications or other forms, such as name, address, age and social security number and
-Information about your coverage from your vision insurer, such as your eligibility for covered services.
We do not disclose personal financial information about our patients or former patients to any third party, except as required or permitted by law.
We restrict access to personal financial information about you to employees who are involved in administering your vision care coverage and providing services to you. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard your personal financial information.
If you would like to have a printed copy of this statement, click File then Print.
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.
Effective: April 14, 2003
Georgia Optometry Group is required by law to protect the privacy of your health information. We are also required to provide you this notice which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.
The terms "information" or "health information" in this notice include any personal information that is created or received by us or your health plan that relates to your physical or mental health or condition, the provision of health care to you, or the payment for such health care.
We reserve the right to change our privacy practices. If we do, we will provide the revised notice to you within 60 days by posting it on our Web site.
HOW WE USE OR DISCLOSE INFORMATION
We must use and disclose your health information:
-To you or someone who has the legal right to act for you (your personal representative)
-To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected and
-Where required by law.
We have the right to use and disclose health information to receive payment for your vision care and operate our business. For example, we may use your health information:
-To Obtain Payment of claims for vision care services you receive from us.
-For Health Care Operations. We may use or disclose vision information, as necessary to manage your vision care coverage with your insurance company.
We may use or disclose your health information for the following purposes under limited circumstances:
-To Persons Involved With Your Care We may use or disclose your health information to a person involved in your care, such as a family member, when you are incapacitated or in an emergency, or when permitted by law another health care provider.
-For Public Health Activities such as reporting disease outbreaks.
-For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities, including a social service or protective service agency.
-For Health Oversight Activities such as governmental audits and fraud and abuse investigations.
-For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
-For Law Enforcement Purposes such as providing limited information to locate a missing person.
-To Avoid a Serious Threat to Health or Safety by, for example, disclosing information to public health agencies.
-For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
-For Workers Compensation including disclosures required by state workers compensation laws of job-related injuries.
-Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
If none of the above reasons applies, then we must get your written authorization to use or disclose your health information. If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is our intent to meet the requirements of the more stringent law. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization, except if we have already acted based on your authorization. Write us to revoke an authorization, refer to "Exercising Your Rights" of this notice for guidance.
HIGHLY CONFIDENTIAL INFORMATION
Federal and Georgia laws require special privacy protections for highly confidential information about you. "Highly confidential information" may include confidential information about alcohol and drug abuse as well as the following types of information:
1. HIV/AIDS
2. Mental health
3. Genetic tests
4. Alcohol and drug abuse
5. Sexually transmitted diseases and reproductive health information and
6. Child or adult abuse or neglect, including sexual assault.
WHAT ARE YOUR RIGHTS
The following are your rights with respect to your health information.
-You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to all restrictions requested.
-You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).
-You have the right to see and obtain a copy of health information that may be used to make decisions about you such as claims and vision management records. You also may receive a summary of this your vision information, such as prescriptions. You must make a written request to inspect and copy your health information at our office(s). You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete. If we deny your request, you may have a statement of your disagreement added to your health information.
-You have the right to receive an accounting of disclosures of your information made by us up to six years prior to your request. This accounting will not include disclosures of information: (i) made prior to April 14, 2003 (ii) for treatment, payment, and vision care operations purposes (iii) to you or pursuant to your authorization and (iv) to correctional institutions or law enforcement officials and (v) other disclosures that federal law does not require us to provide an accounting.
-You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. You are entitled to a paper copy of this notice, if requested, or you may print one from this web site.
EXERCISING YOUR RIGHTS
Contacting your Vision Provider. If you have any questions about this notice or want to exercise any of your rights, please contact Georgia Optometry Group at:770-392-0154, fax 770-698-0612 or by mail:
Attn: HIPAA Compliance
Georgia Optometry Group
Suite E
4651 Chamblee Dunwoody Rd
Atlanta, GA 30338
Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:
Attn: HIPAA Compliance
Georgia Optometry Group
Suite E
4651 Chamblee Dunwoody Rd
Atlanta, GA 30338
You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing privacy rights violation complaint.
FINANCIAL INFORMATION PRIVACY NOTICE
Effective: April 14, 2003
We are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, "personal financial information" means information, other than health information, about you that is not generally publicly available and is collected from the individual or is obtained in connection with providing vision care for you.
We collect personal financial information about you from the following sources:
-Payments you make for your services and materials
-Information we receive from you on applications or other forms, such as name, address, age and social security number and
-Information about your coverage from your vision insurer, such as your eligibility for covered services.
We do not disclose personal financial information about our patients or former patients to any third party, except as required or permitted by law.
We restrict access to personal financial information about you to employees who are involved in administering your vision care coverage and providing services to you. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard your personal financial information.
If you would like to have a printed copy of this statement, click File then Print.