Notice Of Privacy Practices and Patient Bill of Rights
TLC EYECARE & LASER CENTERS
Effective Date: April 14, 2003
Notice of Privacy Practices and Patient Bill of Rights
This Notice of Privacy Practices and Patient Bill of Rights describes how medical information about you may be used and disclosed and how you can access this information under law and, as a patient of this Center, your other rights and obligations. Please review it carefully.
If you have any questions about this Notice please contact the Privacy Officer at 2723 S. State Street, Suite 220, Ann Arbor, MI 48104.
We understand that your medical information is personal and we are committed to protecting your medical information. While you are a patient at this eye care center (“Center”), we create records of the care provided to you. We need these records to provide you with quality health care and to comply with certain legal requirements.
The Privacy Practices describe how we may use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your medical information under law.
The Privacy Practices describe the privacy practices of this Center as well as our affiliated surgeons and optometrists (referred to as “we” throughout this Notice). We will share information with each other as necessary to carry out our respective treatment obligations, payment activities and health care operations.
The Center adopted the Bill of Rights because of our belief that respect for patients’ rights will enhance patients’ experiences and improve the results of the patients’ surgery. The Center used the American Hospital Association’s (AHA) Management Advisory, “A Patient’s Bill of Rights” approved by the AHA Board of Trustees on October 21, 1992, as the foundation for our Bill of Rights with the AHA’s support and encouragement.
The Center has a number of functions to perform, including the immediate and ongoing care of patients, the continuing education of health care professionals, patients, and the community, and basic and clinical research. All of these activities must be conducted with an overriding concern for the values and dignity of our patients.
Your Rights Although the records containing your medical information are the physical property of this Center, the information belongs to you. By law, you have the right to:
- Inspect and copy your medical information. Generally, we will respond to your request within 30 days but, under certain circumstances, we may deny your request.
- Request a restriction on certain uses and disclosures of your medical information; however, we are not required to agree with a requested restriction.
- Request that we communicate with you by using alternative means or at an alternative location.
- Request an amendment of your medical information, if you believe it is inaccurate; however, we may deny your request for amendment if we believe your medical information is accurate.
- Request an accounting of certain disclosures we have made, if any, of your medical information.
- Revoke any authorization you have provided to use or disclose your medical information except to the extent that action has already been taken in reliance on such authorization.
- Obtain a paper copy of this Notice upon request.
We are required to:
- Maintain the privacy of your medical information.
- Provide you with a copy of our Privacy Practices with respect to your medical information.
- Abide by the terms of the Privacy Practices.
- Examples of Permitted Disclosure of Medical Information by this Center
The following are examples of the types of uses and disclosures of your medical information that are permitted (these examples are not meant to be exhaustive).
Treatment. We may use and disclose your medical information to provide, coordinate, or manage your health care and any related services. For example, we may disclose your medical information to the doctors and technicians that care for you while you are undergoing surgery or an optometrist that cares for you after surgery to ensure that they have the necessary information to treat you.
Payment. Your medical information may be disclosed, as needed, to obtain payment from your insurance company or other person responsible for payment for your health care services. For example, we may disclose your medical information to an insurance company so that it can determine your eligibility or coverage for insurance benefits.
Health Care Operations. We may use or disclose your medical information for our internal operations, which include activities necessary to operate this Center and provide our patients with high quality patient care. For example, we may use your medical information for quality improvement purposes to evaluate the care provided to you. We may also use a sign-in sheet at the reception desk asking for your name or call you by name in the waiting area. We may use your medical information to contact you to remind you of appointments, tell you about or recommend possible treatment options or alternatives that may be of interest to you, or inform you about other health related benefits and services that may be of interest to you.
Other Permitted Uses and Disclosures
Unless you object, our staff and the optometrist and surgeons caring for you may disclose your medical information to a family member, relative, close personal friend, or other person that you identify.
- We may be required by law to disclose your medical information.
- We will make your medical information available to you, the Secretary of the Department of Health and Human Services, and as otherwise required by Federal and state law.
- We may disclose your medical information to a public health agency to help prevent or control disease, injury or disability. This may include disclosing your medical information to report certain diseases, death, abuse, neglect or domestic violence or reporting information to the Food and Drug Administration, if you experience an adverse reaction from any of the drugs, supplies or equipment that we use.
- We may disclose your medical information to government agencies so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs.
- We may disclose your medical information as authorized by law to comply with workers’ compensation laws.
- We may disclose your medical information in the course of a judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in response to a subpoena, discovery request, or other lawful process.
- We may disclose your medical information to law enforcement officials to report or prevent a crime, locate or identify a suspect, fugitive or material witness or assist a victim of a crime.
- We may use or disclose medical information for research purposes when the research received approval of an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your medical information.
- If you are a member of the armed forces, we may disclose your medical information as required by military command authorities or to evaluate your eligibility for veteran’s benefits, for conducting national security and intelligence activities, including providing protective services to the President or other persons provided protective services under Federal law.
- We may disclose your medical information to coroners, medical examiners and funeral directors so that they can carry out their duties or for purposes of identification or determining cause of death.
- We may disclose your medical information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.
- We may share your medical information with third party “business associates” that perform various services for us. For example, we may disclose your medical information to third parties to provide billing or copying services. To protect your medical information, however, we require our business associates to safeguard your medical information.
Authorization. For uses and disclosures of your medical information beyond the uses and disclosures described in the Privacy Practices or as authorized or required by law, we are required to obtain your written authorization. You may revoke an authorization in writing at any time to stop any future use or disclosures by us with certain limited exceptions.
Bill of Rights
Your Rights and Our Responsibilities
You have a right to:
- Considerate and respectful care.
- Obtain from your health care professionals and other direct providers of patient care services relevant, current, and understandable information concerning diagnosis, treatment, and prognosis know the identity of the your care professionals, and others involved in their care and their credentials, as well as when those care providers are students, residents, or other trainees.
- Know the immediate and long-term financial implications of treatment choices, if known.
- Make decisions about the plan of care prior to and during the course of treatment.
- Refuse a recommended treatment or plan of care to the extent permitted by law and standard operating procedures of the Center and to be informed of the consequences of this action. In case of such refusal, you are entitled to other appropriate care and services that the Center provides or transfer to another provider of health care services. The Center should notify you of any policy that might affect patient choice.
- Have the information contained in your record explained or interpreted as necessary, except where restricted by law.
- Expect that, within its capacity and policies, the Center will, within reason, respond to your request for appropriate health care services. The Center must provide evaluation, service, and/or referral appropriate to your condition. When clinically appropriate and legally permissible, or at your request, your care may be transferred to another health care professional, provided the health care professional has accepted your transfer.
- Ask for and be informed of the existence of business relationships among the Center, manufacturers of products and services, educational institutions, other health care professionals, and/or payers, if any, that might influence your treatment and care.
- Consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. If you decline to participate in research or experimentation, you are entitled to the most effective care that the Center can otherwise provide.
- Expect reasonable continuity of care when appropriate and to be informed by your health care professionals and others participating in your care of available and realistic patient care options when care within the Center is no longer appropriate.
- Be informed of the policies and practices of the Center that relate to your care and the responsibilities of providers of health care services.
- Be informed of available resources for resolving disputes, grievances, and conflicts.
- Be informed of the fees for services provided by your health care professionals and the Center.
The collaborative nature of health care requires that a patient (and their family members/guardian and/or Personal Representative) participate in their care. The effectiveness of care and patient satisfaction depends, in part, on the patient fulfilling certain responsibilities. You are responsible for providing information about past illnesses, hospitalizations, medications, and other matters related to your health. To participate effectively in decision-making, you must take responsibility for requesting additional information or clarification about your condition or treatment when you do not fully understand information and/or instructions. You are also responsible for informing your health care professionals if you anticipate problems following the prescribed treatment or post-operative care.
You should be aware of the Center’s obligation to be reasonable, efficient and equitable in providing care to other patients and the community; the Center’s policies and standard operating procedures are designed to fulfill this obligation. You are responsible for making reasonable accommodations for the needs of other patients, the professional staff and employees of the Center. You are responsible for providing necessary information for insurance claims and working with the Center to make payment arrangements, when necessary.
Your vision depends on much more than the health care you receive at the Center. As a result, you are responsible for recognizing the impact of your life-style on the health of your eyes and vision.
Changes to this Notice
By law, we must abide by the terms of the Privacy Practices; however, we reserve the right to change our Privacy Practices and/or this Notice. If we revise this Notice, the new Notice will be effective for all medical information we maintain. Any new Notices will be available by accessing the website, www.tlceyecare.com, calling 1-800-551-7347 and requesting that a copy be sent to you in the mail, or asking for a copy at the time of your next appointment or visit.
Your Personal Representative may exercise your rights on your behalf. A Personal Representative may include your guardian if you are a minor, lack decision-making capacity or are legally incompetent, or a person you have authorized to act on your behalf as specified in a written document (such as a power of attorney).
For More Information or to Report a Complaint
If you have questions or would like more information about this Notice, you may contact the Privacy Officer at 2723 S. State Street, Suite 220, Ann Arbor, MI 48104.
If you believe your privacy rights have been violated, you may file a written compliant with the Privacy Officer or the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Effective Date: April 14, 2003.
Date Revised: ____________