Notice of Private Policies and Consent
This notice describes how your medical information may be used and disclosed and what rights you have. Please review it carefully.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
By law, we are allowed to use or disclose your Protected Health Information (PHI) without your written consent for the purpose of treatment, payment, or health care operations. Examples include scheduling appointments; examinations; prescribing corrective lenses, vision aides, or medications and providing prescription information to suppliers; referrals for other medical care; getting copies of past records; acquiring guarantor/insurance information; processing bills or claims; financial or billing audits; internal quality assurance; personnel decisions; credentialing; legal defense; business planning and record storage. You have the right to request that we not release this information to your health insurance company only when you pay cash for services.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some other limited situations, the law allows us to use or disclose your PHI without your permission. Examples include disclosures required by law, subpoenas or court orders; reporting threats to health or safety; suspected abuse or neglect; knowledge relating to a crime; public health oversight; organ procurement; worker's compensation disclosures; incidental disclosures; de-identified information; "limited data sets" for research and disclosures to "business associates" who are under contractual obligation to respect the privacy of your PHI. Any information that is disclosed will be limited to the minimum information required and will only be given to parties with the proper authorization to obtain this information. Unless you object, we will also share relevant information about your care with family or designated friends helping with your care. Relevant information may include, but is not limited to, making or changing appointments, the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Triad Eye Center staff will also assist individuals on a patient’s behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s vision or health status may be disclosed without proper patient consent. Triad Eye Center staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual.
APPOINTMENT REMINDERS/ NOTIFICATIONS
We may call, write or email you to notify you of routine examinations due, appointment confirmation, order status or services available at our office. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard and/or call you at the number you have given us. We may leave a message if you are not available.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your PHI unless you sign a written “authorization form,” the content of which is determined by federal law. The authorization may be revoked at any time by writing to the contact below.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
All requests must be made in writing and will be responded to within the time allowed by law (usually 30 days). You may ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to this, but if we do, we must honor the restrictions that you want. You may ask us to communicate with you in a confidential way, such as using a specific telephone number or address. We will accommodate reasonable requests. There may be a charge for any additional cost involved with the request. You may ask to see or to get photocopies or an electronic copy of your PHI. You may have to pay for photocopies in advance. By law, there are a few limited situations in which we can refuse to permit access or copying. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. If we do not agree, a statement of your position and any rebuttal statement that we may write will be included in your PHI and will be included anytime we disclose your PHI. You may ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask and will notify the persons who initially sent the incorrect information. If we do not agree, you can write a statement of your positions, and we will include it with your health information along with any rebuttal statement that we may write. This statement and rebuttal will become a part of your PHI to be released with any future disclosures of PHI. You may request a list of our disclosures for your PHI. By law, this list will not include: disclosures for personal treatment, payment or health care operations, disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. In the event of a breach of unsecured protected health information, all patients affected will receive immediate notification of this breach. You can receive additional paper copies of this Notice of Privacy Practices upon request.
OUR NOTICE OF PRIVACY PRACTICES (NPP)
We are obligated by law to protect your PHI and to abide by the terms of this NPP. We reserve the right to change this notice at any time as allowed by law. Any changes in our NPP will be available in our office and on our website and will apply to any PHI that we already have as well as any that we may generate in the future. COMPLAINTS If you think we have not properly respected the privacy of your PHI, please contact our Privacy Officer listed below. If we are unable to resolve your concern, you may also file a complaint with the U.S. Dept. of Health and Human Service, Office for Civil Rights or the state Attorney General's Office to discuss your complaint without fear of retaliation.
CONTACT INFORMATION
For more information about our privacy practices you may call, write or visit our office at the address below. All requests concerning your PHI must be made in writing to:

Andrea Wisniewski
Westchester Eye Care
752 Middletown Road,
Colchester, CT 06415
I have read this document and understand it. By typing my first and last name below I consent to the use and disclosure of my health information for the purposes of treatment, payment, and healthcare operations. *
If the above name is a personal representative of the patient, describe the relationship to the patient.
Patient's first and last name. *
Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy