Notice of Privacy Practices Form

Download our Notice of Privacy Practices (PDF)

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 Novice please contact our Privacy Officer, Sherrie Kleekamp.

This Notice of Privacy Practices describes how we may use and disclose your protected healthy information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related healthcare services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective or all protected health information that we maintain at that time. We will provide you with any revised Novice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your appointment.

Uses and Disclosures of Protected healthy Information for Treatment, Payment, and Healthcare Operations Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that has already obtained your permission to have access to your protected health information. For example, results from laboratory tests and other procedures will be available in your medical record to all health professional who may provide treatment or who may be consulted by your physician or other medical staff members. In addition, we may disclose your protected health information from time to time to another physician or healthcare provider who, at the request of your physician becomes involved in your care by providing assistance with your healthcare diagnosis or treatment to your physician.

Payment: Your protected health information will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as making a determination of eligibility or coverage for insurance benefits; reviewing services provided to you for medical necessity; and undertaking utilization review activities. For example, obtaining approval for a surgery may require that your relevant protected health information be disclosed to the healthy plan to obtain approval for the surgery.

Healthcare Operations: We may use or disclose, as needed, your protected health information to medical school students that will observe patients care in our office. We also may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party “business associates” that perform various services (e.g., billing, legal services or transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that we will protect the privacy of your protected health information in the hand of our business associates.

Additional uses of Information: Appointment reminders will be sent out in the mail that will include your health information. Reminder calls of your appointment will be made to your home. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition (newsletter). We may also send you information describing other health-related products and services that we believe may interest you. You may contact our Privacy Officer to request that these materials not be sent to you. 

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. 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 of disclosure of information that occurred before you notified us of your decision to revoke your authorization.

You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree to or object to the use or disclosure of the protected health information, then your physician may, using his or her professional judgment, determine whether the discloser is in your best interest. In this case, only the protected health information that is relevant to your healthcare will be disclosed.

Family Members or Others Involved in Your Healthcare: Unless you object, we may disclose to members of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your healthcare. If you are unable to agree to or object to such a disclosure, we may disclose such information as necessary if a determination is made that is in your best interest based on our professional judgment.

Emergencies: Your protected health information may be used or disclosed in an emergency treatment situation. Your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician has attempted to obtain your consent but is unable to obtain it, he or she may still use or disclose your protected health information to treat you.

The following are permitted and required uses and disclosure that may be made without your consent or authorization, or opportunity to object.

We may use or disclose your protected health information to the extent that law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. We are required by law to report child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. Information may also be disclosed to a health oversight agency for activities authorized by law, such as audits, investigations and inspections of government benefit programs, government regulatory programs and civil rights laws.

Law Enforcement: Your health information may be disclosed to law enforcement agencies, so long as applicable legal requirements are met. These law enforcement purposes include: legal processes and limited information request for identification and location purposes, pertaining to victims of crime, suspicion that death has occurred as a result of criminal conduct, in the event that a crime occurs on the premises of the practice, and medical emergency (not on the practice’s premises) and it is likely that a crime has occurred. Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety to the public.

Legal Proceeding: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process.

Food and Drug Administration: We may disclose health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, to enable product recalls, to make repairs or replacements.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. Protected health information may be used and disclosed for cadaver organ, eye, or tissue donation purposes.

Research: We may disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of foreign military authority if you are a member of that foreign military services. We also may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: If you are an inmate of a correctional facility your protected health information will be disclosed to that facility as long as you are incarcerated in that facility. Only information that is obtained while you are an inmate of that facility will be disclosed.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine or compliance with the requirements of Title 45, Section 164.500 et.seq. of the Code of Federal Regulations.

YOUR RIGHTS

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about you.

Under federal law, however, you may inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceedings, and protected health informant that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances you may have a right to have this decision reviewed. Please contact our Privacy Office if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You also may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, 3 of 4 please discuss any restriction you which to request with the Privacy Officer. You may request a restriction by submitting your request in writing or fill out the appropriate form. Please contact our Privacy Officer.

You may have the right to request that your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request to an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have question about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members, or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request disclosures for a shorter time period. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to obtain a paper copy of this notice from our practice.

COMPLAINTS

You may complain to the Secretary of Health and Human Services or us if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. Please contact our Privacy Officer, Sherrie Kleekamp, COT at 314-839-1211. This notice was published and becomes effective April 14, 2003.

Acknowledgement of Receipt of Notice of Privacy Practices

Retina Associates of St. Louis, Inc. reserves the right to modify the privacy practices outlined in the notice.

Yes, I have received a copy of the Notice of Privacy Practices for Retina Associates of St. Louis, Inc.



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