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.

Wyse Eyecare S.C. is required by law to maintain the privacy of Protected Health Information (PHI) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present, future physical and/or mental health condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes.

Our staff is required to follow the terms of this notice. We will not use or disclose PHI about you without your written authorization except as described in this notice. We reserve the right to change our practices and this notice to make the new notice effective for all PHI we maintain.

Uses and Disclosures of Your Health Information

Treatment.

Your protected health information (PHI) will be used by our physicians and staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medication conditions, and providing treatment. For example, your health information may be disclosed to a pharmacy relative to the medications we prescribed for your care.

We will send you a postcard to let you know it is time for your next appointment. A day or two before you appointment we will telephone to remind you.

Payment.

Your protected health information (PHI) will be used to seek payment from your health care coverage such as Medicare or Blue Cross/Blue Shield or other payer(s) on your behalf. It could include activities such as confirming coverage and copays, submitting claims for you and following up for payment.

Health Care Operations

Your PHI is used only as necessary in the functions of our practice. For example, when monitoring quality control, auditing office procedures, cost-management analysis and customer service.

Business Associates.

Our office provides some services to you through contract with a business associate. In these cases your PHI is provided so the business associate may provide the requested service. For example, we may submit a claim to your insurance company to an electronic service. To protect your privacy we require the associate to safeguard the information.

Individuals Involved in Your Care

Using our professional judgment, we may disclose to a family member, other relative, close personal friend, or any person you identify, PHI relevant to that person’s involvement in your care or payment for your care.

Law Enforcement

Your PHI may be disclosed to law enforcement agencies. To support government audits and inspections, to facilitate law enforcement investigations and to comply with government mandated reporting.

Judicial and Administrative Proceedings

If you are involved in a lawsuit or a dispute we may disclose PHI about you in response to a subpoena, discover request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested information.

Public Health Reporting.

Your PHI may be disclosed to public health and governmental agencies as required by law. For example, our practice is required to report certain communicable diseases to the Illinois Department of Public Health.

Research.

We are permitted to use or disclose protected health information about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors.

We may release PHI about you to a coroner, medical examiner and/or funeral director.

Organ or Tissue Procurement Organizations.

Consistent with applicable law, we may disclose PHI about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation or organs to the purpose of tissue donation and transplant.

Notification.

We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location and the safety of others.

Correctional Institution.

If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for the health and safety of the public or another person.

To Avert a Serious Threat to Health or Safety.

We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military and Veterans.

If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.

National Security and Intelligence Activities.

We may disclose PHI about you to authorized federal officials for the intelligence, counterintelligence and other national security activities authorized by law.

Protective Services for the President and Others.

We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, foreign heads of state, or those conducting special investigations.

Victims of Abuse, Neglect, Or Domestic Violence.

We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonable believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law if you agree to the disclosure or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.

Information about Treatments.

Your health information may be used to send you information about treatment or management of your medical condition that you may find of interest.

Your Health Information Rights

You may request a copy of this notice for your own records. Any of our staff will be happy to give you your own copy.

You have the right to request additional restrictions on how we use your PHI. Send your request to our office to the attention of our HIPPA Privacy Officer – Leah Foster.

We will give your request serious consideration and comply if practical. However we are not required to meet your request.

You are entitled to a copy of your own medical record as long as we have it on file. Should you wish to have a copy, simply complete our Request for Release of Record form. We may charge a fee for the service and copying charges related to your request. In certain circumstances, your request may be denied, in which case you may request of review of the denial.

You have the right to request an amendment to your medical record as long as we have it on file should you feel the record is incomplete or incorrect. Notify us of your request in writing, including the reason for your request. If you request is denied you have the right to submit a statement of disagreement and we may give a rebuttal to your statement.

You have the right to see an accounting of the disclosures we have made of PHI about you for purposes other than treatment, payment or health care operations. The accounting will exclude the following: disclosures made directly to you, disclosures to friends or family members involved in your case, disclosures for notification, restrictions and limitations. You must submit your request to our office in Northbrook to the attention of Leah Foster, our HIPPA Privacy Officer.

You must specify the time frame (not to exceed six years).

You have the right to request alternate means of communication. For instance, you may request that we contact you about medical matters only in writing or at a difference residence or post office box. Submit your request in writing to our Northbrook office to the attention of Leah Foster, our HIPPA Privacy Officer, stating how or where you would like to be contacted. We will honor all reasonable requests.

Your Authorization Required for Other Uses

Disclosures of uses of your PHI for a purpose other than those listed above requires your specific written authorization. As always, we will not proceed with a request other than the above without your written authorization.