DRS. NORTH & WATSON OPTOMETRISTS, P. A.

NOTICE OF PRIVACY PRACTICES

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.

The Health Insurance Portability Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for misuse of personal health information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information, and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes:
Treatment, Payment, and Health Care Operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of this include eye examinations, prescriptions and contact lens fittings.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
• Health Care Operations include the business aspects of running our practice, such as conduction quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

In some cases, the law allows or requires us to use your health information without your permission. We will use only the minimum necessary amount of protected health information to satisfy the purpose of the request. Such uses or disclosures maybe:

• When a state or 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 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
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
• Uses and disclosures to prevent a serious threat to health or safety
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures

NOTICE OF PRIVACY PRACTICES

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you request in writing to remove it
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations
• The right to inspect and ask for a copy of your protected health information
• The right to receive an accounting of disclosures of protected health information
• The right to obtain a paper copy of this notice from us upon request

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices, and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information:
Drs. North & Watson, Optometrists, P. A.
Rosedale Commons
2480 Fairview Ave North
Roseville, MN 55113
Telephone # (651) 639-0407

For more information about HIPAA or to file a complaint:
The US Dept of Health & Human Services
Office of Civil Rights
200 Independence Ave, S.W.
Washington, D.C. 20201
Telephone # (202) 619-0257
Toll Free: 1-877-696-6775
E-mail: info@northandwatson.com