Privacy Notice
Viva Eye Care
Notice of Privacy Practices
5901 Bellaire Blvd., Ste 100
Houston, TX 77081
Effective 04/14/2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION THE "OFFICE" PERTAINS TO "VIVA EYE CARE."
PLEASE REVIEW IT CAREFULLY.
The Office is required by law to maintain the privacy of your health information, to the follow items of this notice, and to provide you with this notice of our and privacy practices. We will not us or disclose medical information about you without your written authorization, except as described in this NOTICE. If your state law provides additional restrictions upon any of the forgoing uses and disclosures, we must follow your state law.
How the Office May Use or Disclose Your Health Information Treatment, Payment, and Regular Health Care Operations Information obtained by the Office will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request.
As and When Required by Law We may use and disclose your health information to Public Health Officials, Health Oversight Activities (For audits, investigations, etc.), Judicial and Administrative, Deceased Person Information, Worker Compensation programs, Food and Drug Administration (for reporting adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the Military or a Veteran of the armed forces, or if you become an inmate in a correctional facility.
Personal Communications
We may contact you or individuals involved in your care or payment of your care to provide appointment reminders, annual eye examination cards and other information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Disclosures to our Business Associates
We may provide some services though contracts with business associates (accounting, etc.) When necessary, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, we require our business associated to appropriately safeguard your health information.
Victims of Abuse, Neglect, or Domestic Violence
We may disclose your health to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
Marketing Communications
We must obtain your written authorization prior to using your health information to send you any general marketing
materials. We may contact you about products or services relating to your treatment, care or alternative treatments, or providers without prior authorization.
If you would like to exercise on or more of these rights, need additional information, or believe your privacy right have been violated, contact the location provided your services at the address above. There will be no retaliation.
Changes to this Notice of Privacy Practice
The Office reserves the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new Notice effective for all medical information we maintain. Until such amendment is made, the Office is required by law to comply with this Notice.
My signature on the Office's "Welcome Form" indicates that I have read and understand the Privacy Practice as stated above. I hereby authorize the disclosure of my health information as described in this form.
Notice of Privacy Practices
5901 Bellaire Blvd., Ste 100
Houston, TX 77081
Effective 04/14/2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION THE "OFFICE" PERTAINS TO "VIVA EYE CARE."
PLEASE REVIEW IT CAREFULLY.
The Office is required by law to maintain the privacy of your health information, to the follow items of this notice, and to provide you with this notice of our and privacy practices. We will not us or disclose medical information about you without your written authorization, except as described in this NOTICE. If your state law provides additional restrictions upon any of the forgoing uses and disclosures, we must follow your state law.
How the Office May Use or Disclose Your Health Information Treatment, Payment, and Regular Health Care Operations Information obtained by the Office will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request.
As and When Required by Law We may use and disclose your health information to Public Health Officials, Health Oversight Activities (For audits, investigations, etc.), Judicial and Administrative, Deceased Person Information, Worker Compensation programs, Food and Drug Administration (for reporting adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the Military or a Veteran of the armed forces, or if you become an inmate in a correctional facility.
Personal Communications
We may contact you or individuals involved in your care or payment of your care to provide appointment reminders, annual eye examination cards and other information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Disclosures to our Business Associates
We may provide some services though contracts with business associates (accounting, etc.) When necessary, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, we require our business associated to appropriately safeguard your health information.
Victims of Abuse, Neglect, or Domestic Violence
We may disclose your health to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
Marketing Communications
We must obtain your written authorization prior to using your health information to send you any general marketing
materials. We may contact you about products or services relating to your treatment, care or alternative treatments, or providers without prior authorization.
- Your Rights with Respect to Your Health Information
- You have the right to request restrictions on certain uses and disclosures of your health information. The Office is not required to agree to the restriction that you requested.
- You have the right to inspect and copy your health information (prescription, billing records, etc.) as long as the Office maintains the health information. To inspect or copy your health information, you must submit a written request to the location that provided your services. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant you request. We may deny your request to inspect and copy under certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have the right to request that the Office amend your health information that you believe is incorrect or incomplete. The Office is not required to change your health information and will provide you with information about the procedure for addressing any disagreement with the denial.
- You have the right to receive an accounting of disclosures of your health information we have made since April 14, 2003 for most purposes other than treatment, payment, health care operations provided to you, and certain government functions. You must specify the time period but be no longer than six years. We will notify you of the cost involved and you choose to withdraw or modify you request at that time.
- You may request communications of your health information by alternative means or at the alternative locations. For example, you may request that we contact you about medical matters or at different residence or post office obs. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.
If you would like to exercise on or more of these rights, need additional information, or believe your privacy right have been violated, contact the location provided your services at the address above. There will be no retaliation.
Changes to this Notice of Privacy Practice
The Office reserves the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new Notice effective for all medical information we maintain. Until such amendment is made, the Office is required by law to comply with this Notice.
My signature on the Office's "Welcome Form" indicates that I have read and understand the Privacy Practice as stated above. I hereby authorize the disclosure of my health information as described in this form.
