Effective Date of Notice: 4/14/2003
Notice of Privacy Practices
Lori Macfarlane, O.D.
Phillip Ruprecht, O.D.
McKinleyville Optometric Center
1933A Central Ave
McKinleyville, CA 95519
Phone: (707) 839-4758
Fax: (707) 839-3715
Contact Person: Phillip Ruprecht
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. This Notice describes
how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment, or
health care operations. Examples of how we use or disclose information for treatment purposes are: setting
up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye
medications and faxing them to be filled; referring you to another doctor or clinic for eye care; or getting
copies of your health information from another professional that you may have seen before us. Examples of
how we use or disclose your health information for payment purposes are: asking you about your health or
vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid
amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those
administrative and managerial functions that we have to do in order to run our office. Examples of how we
use or disclose your health information for health care operations are: financial or billing audits; internal
quality assurance; personnel decisions; participation in managed care plans; defense of legal matters;
business planning; and outside storage of our records. We routinely use your health information inside
our office for these purposes without any special permission. If we need to disclose your health information
outside of our office for these reasons, we usually will not ask you for special written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information
without your permission. Not all of these situations will apply to us; some may never come up at our office
at all. Such uses or disclosures are:
- when a state for federal law mandates that certain health information be reported for a specific purpose;
- for public health purposes, such as contagious disease reporting, investigation, or surveillance; and
notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- disclosures to government authorities about victims of suspected abuse, neglect, or domestic violence;
- uses and disclosures for health oversight activities, such as licensing of doctors; for audits by Medicare or
Medicaid; or for investigation of possible violations of health care laws;
- disclosure for judicial and administrative proceedings, such as in response to subpoenas or orders of
courts or administrative agencies;
- disclosures for law enforcement purposes, such as to provide information about someone who is or is
suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime
that happened somewhere else;
- disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to
funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- uses or disclosures for health related research;
- uses or disclosures to prevent a serious threat to health or safety;
- uses or disclosures for specialized government functions, such as for the protection of the president or
high ranking government officials; for lawful national intelligence activities; for military purposes; or for the
evaluation and health of members of the foreign service;
- disclosures of de-identified information;
- disclosures relating to worker's compensation programs;
- incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- disclosures to "business associates" who perform healthcare operations for us and who commit to
respect the privacy of your health information;
Unless you object , we will also share relevant information with your family or friends who are helping
you with your eye care.
We may call or write to remind you of scheduled appointments, or that it is time to make a routine
appointment. We may call or write to notify you of other treatments or services available at our office that
might help you. Unless you tell us otherwise, we will mail you an appointment reminer on a post card, and/or
leave you a reminder message on your home answering machine or with someone who answers your phone
if you are not at home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written
"authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we
may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the
process if it's your idea for us to send your information to someone else. Typically, in this situation you will
give us a properly completed authorization form, or you can use one of ours. If we initiate the process and
ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we
cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already
acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at
the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
- ask us not to share information about your treatment with your insurance company in cases where you
pay for those services out of pocket.
- expect to be notified in the event that we discover that your health information has been breached and
the privacy of the information is likely to have been compromised. We must notify you of the breach without
unreasonable delay and in no event later than 60 days following our discovery of the breach.
- 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 do this, but if we agree, we must honor the
restrictions that you want. To ask for a restriction send a written request to the office contact person at the
address or fax number shown at the beginning of this Notice.
- ask us to communicate with you in a confidential way, such as by phoning you at work rather than at
home, mailing health information to a different address, or by using email to your personal email address. We
will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to
ask for confidential communications, send a written request to the office contact person at the address or fax
number shown at the beginning of this Notice.
- ask to see or get photocopies of your health information. By law, there are a few limited situations in
which we can refuse to permit access or copying. For the most part, however, you will be able to review or
have a copy of your health information within 30 days of asking us (or sixty days if the information is stored
off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a
written explanation, and instructions on how to get an impartial review of our denial if one is legally available.
By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send
you a written notice of the extension. If you want to review or get photocopies of your health information,
send a written request to the office contact person at the address or fax number shown at the beginning of
- ask us to amend your health information if you think it is incorrect or incomplete. If we agree, we will
amend the information within 60 from when you ask us. We will send the corrected information to persons
who we know got the wrong information, and others that you specify. If we do not agree, you can write a
statement of your position, and we will include it with your health information along with any rebuttal
statement that we may write. Once your statement of position and/or our rebuttal is included in your health
information, we will send it along whenever we make a permitted disclosure of your health information. By
law, we can have one 30 day extension of time to consider a request for amendment if we notify you in
writing of the extension. If you want to ask us to amend your health information, send a written request,
including your reasons for the amendment, to the office contact person at the address or fax number shown
at the beginning of this Notice.
- get a list of the disclosures that we have made of your health information within the past six years (or a
shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment,
or healthcare operations; disclosures with your authorization; incidental disclosures; disclosures required by
law; and some other limited disclosures. You are entitled to one list per year without charge. If you want
more frequent lists, you will have to pay for them in advance. We will usually respond to your request within
60 days of recieving it, but by law we can have one 30 day extension of time if we notify you of the
extension in writing. If you want a list, send a written request to the office contact person at the address or
fax number shown at the beginning of this Notice.
- get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether
you got one electronically or in paper form already. If you want additional paper copies, send a written
request to the office contact person at the address or fax number shown at the beginning of this Notice.
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 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 notice in our
office, have copies available in our office, and post it on our Website.
If you think that we have not properly respected the privacy of your health information, you are fee 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 email 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.