Effective date of notice: January 2014
NOTICE OF PRIVACY PRACTICES
Michael W. Hansen, O.D., Inc.
2101 Rosecrans Ave. Suite 1215, El Segundo, CA 90245
310-321-6990 Fax 310-321-6170 – Email info@advancedeyecarecenter.net
310 Avenue I, Redondo Beach, CA 90277
310-373-3191 Fax 310-373-3979 – Email frontdesk@advancedeyecarecenter.net
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.
We respect our legal obligation to keep health information that identifies you private. We
are obligated by law to give you notice of our privacy practices. This Notice describes how we
protect your health information and what rights you have regarding it.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your
rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record. You can ask to see or get an electronic
or paper copy of your medical record and other health information we have about you. Ask us
how to do this. We will provide a copy or a summary of your health information, usually within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record. You can ask us to correct health information about you
that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your
request, but we’ll tell you why in writing within 60 days.
Request confidential communications. You can ask us to contact you in a specific way (for
example, home or office phone) or to send mail to a different address. We will say “yes” to all
reasonable requests.
Ask us to limit what we use or share. You can ask us not to use or share certain health
information for treatment, payment, or our operations. We are not required to agree to your
request, and we may say “no” if it would affect your care. If you pay for a service or health care
item out-of-pocket in full, you can ask us not to share that information for the purpose of
payment or our operations with your health insurer. We will say “yes” unless a law requires us
to share that information.
Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of
the times we’ve shared your health information for six years prior to the date you ask, who we
shared it with, and why. We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures (such as any you asked us to
make).
Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if
you have agreed to receive the notice electronically. We will provide you with a paper copy
promptly.
Choose someone to act for you. If you have given someone medical power of attorney or if
someone is your legal guardian, that person can exercise your rights and make choices about
your health information.
File a complaint if you feel your rights are violated. You can complain if you feel we have
violated your rights by contacting us at (310)-568-0193. You can file a complaint with the U.S.
Department of Health and Human Services Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a
complaint.
YOUR CHOICES
For certain health information, you can tell us your choices about what we share. If you have a
clear preference for how we share your information in the situations described below, talk to us.
Tell us what you want us to do, and we will follow your instructions. In these cases, you have
both the right and choice to tell us to 1) Share information with your family, close friends, or
others involved in your care 2) Share information in a disaster relief situation 3) Include your
information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go
ahead and share your information if we believe it is in your best interest. We may also share
your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission: 1)
Marketing purposes 2) Sale of your information 3) Fundraising – We may contact you for
fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES
How do we typically use or share your health information?
We typically use or share your health information in the following ways. 1) Treat you. We can use your health information and share it with other professionals who are treating you. 2) Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary. 3) Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues. We can share health information about you for certain situations such as 1) Preventing disease 2) Helping with product recalls 3) Reporting adverse reactions to medications 4) Reporting suspected abuse, neglect, or domestic violence 5) Preventing or reducing a serious threat to anyone’s health or safety.
Do research. We can use or share your information for health research.
Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you: 1) For workers’ compensation claims 2) For law enforcement purposes or with a law enforcement official 3) With health oversight agencies for activities authorized by law 4) For special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
OUR RESPONSIBILITIES
1) We are required by law to maintain the privacy and security of your protected health information. 2) We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. 3) We must follow the duties and privacy practices described in this notice and give you a copy of it. 4) We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 5) For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. 6) Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new one in our office and have copies available in our office.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax, or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
NOTICE OF PRIVACY PRACTICES
Michael W. Hansen, O.D., Inc.
2101 Rosecrans Ave. Suite 1215, El Segundo, CA 90245
310-321-6990 Fax 310-321-6170 – Email info@advancedeyecarecenter.net
310 Avenue I, Redondo Beach, CA 90277 310-373-3191 Fax 310-373-3979 – Email frontdesk@advancedeyecarecenter.net
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Michael W. Hansen, O.D., Inc. Notice of Privacy Practices.
Patient name
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___________________________________________________Date_______________________