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 THIS INFORMATION CAREFULLY.
Cape Cod Eye Surgery & Laser Center Duties
This notice describes the privacy practices of Cape Cod Eye Surgery and Laser Center and its physicians, nurses and other personnel (“CCESLC”). We are required by law to maintain the privacy of your medical information and to provide you with this notice of privacy practices. In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as your name, address and phone number, your insurance information, your medical history, and the names of your other health care providers. We will also gather information about you and create a record of the care provided to you. Some of your other doctors may also give us information about you. We are committed to abide by the privacy policies and practices that are outlined in this notice to protect your medical information.
How We May Use and Disclose Information About You
The following categories describe different ways that we use and disclose your medical information. Please note that not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories:
Treatment. Your medical information may be used by our physicians, optometrists, fellows, technicians and other personnel and, with your consent, disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.
Payment. Your medical information may be used and, with your consent, disclosed to seek payment from your health plan, workman’s compensation, other sources of coverage such as an automobile insurer, or credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. With your consent, we may also disclose medical information to your health plan to assist another health care provider obtaining payment for services rendered to you.
Health Care Operations. Your medical information may be used and, with your consent, disclosed as necessary to support the day-to-day activities and management of CCESLC. For example, information on the services you received may be used and/or disclosed to others to support budgeting and ﬁnancial reporting and activities to evaluate and promote quality to insure that our practice is meeting state and federal guidelines and laws designated to protect your medical information. With your consent, we may disclose your medical information to another health care provider in connection with the other health care provider’s health care operations.
Information about treatments. Your medical information may be used to send you information on the treatment and management of your medical condition that you may ﬁnd of interest. We may also send you information describing other health-related goods and services that we believe may interest you. Most uses and disclosures of your medical information for purposes of marketing will require your prior authorization.
Disclosures to Persons Assisting in Your Care. We may disclose your personal information to individuals involved in your care such as a family member, other relative or close personal friend who may be involved in your care. We will generally obtain your verbal agreement before using or disclosing your information in this way. In certain circumstances, such as in an emergency situation, we may make these uses and disclosures without your agreement.
Public Health Reporting. Your medical information may be disclosed to public health agencies as required by law. For instance, we are required to report (1) cases of child abuse or neglect, elder abuse, and disabled persons abuse; (2) medical information for the purpose of preventing or controlling disease, injury or disability; (3) information about products and services under the jurisdiction of the U.S. Food and Drug Administration; and (4) information to your insurer and/or the Massachusetts Industrial Accident Board (and any party involved in the Workers’ Compensation matter) as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Health Oversight Activities. Your medical information may be disclosed to health oversight agencies as required by law. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal or administrative proceedings or actions. We are also required to disclose your medical information to the Secretary of Health and Human Services, upon request, to determine our compliance with the Health Insurance Portability and Accountability Act.
Health and Safety. We may use or disclose your medical information to prevent or lessen a serious and imminent danger to you or to others if the disclosure is to a person who is reasonably able to lessen or prevent the threat, including the target of the threat. We may also disclose your medical information for disaster relief efforts.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your medical information in response to a court order or a subpoena, discovery request or other lawful process accompanied by a court order. We may also use your medical information to defend ourselves or any member of CCESLC in a threatened or actual legal action.
Law Enforcement Ofﬁcials. Your medical information 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 (for example to report rape, sexual assault and certain type of wounds).
National Security. We may disclose your medical information for national security and intelligence activities and for the provision of protective services to the President of the United States and other ofﬁcials or foreign heads of state.
Members of the Armed Forces. We may release your medical information for activities deemed necessary by military command authorities. We may also release medical information about foreign military personnel to their appropriate foreign military authority.
Inmates. We may release your medical information to a correctional institution where you are conﬁned or to law enforcement ofﬁcials in certain situations such as where the information is necessary for your treatment, health or safety, or the health or safety of others.
Research. Your information may be used for research or studies into the effectiveness of care provided in the past by CCESLC. If your information is used in such a way, we will remove anything that can identify the information as pertaining to you as an individual. We will not proceed with research of this type until we have received approval from an independent review board, which will conﬁrm that individually identiﬁable patient information is removed. If you are a candidate for active studies or research, we will inform you of your eligibility and ask for your speciﬁc authorization before we use your information in an active study. You may decline participation in any research conducted by CCESLC by talking to your personal eye doctor.
Sale of Medical Information. Disclosures that constitute a sale of information require your authorization.
Required by Law. We will disclose your medical information when required to do so by federal, state or local law.
Other uses and disclosures require your authorization. Disclosure of your medical information or its use for any purpose other than those listed above requires your speciﬁc written authorization. We will not deny medical treatment if you do not sign this authorization.
Highly Conﬁdential Information. Federal and state law require special privacy protections for certain highly conﬁdential information about you (“Highly Conﬁdential Information”), including: (1) your HIV/AIDS status; (2) substance abuse (alcohol or drug) treatment or rehabilitation information;
(3) treatment or diagnosis of emancipated minors; and (4) research involving controlled substances. In order for us to disclose your Highly Conﬁdential Information we must obtain your separate, speciﬁc written consent and/or authorization unless we are otherwise permitted by law to make such disclosure.
In addition, if you are an emancipated minor, certain information relating to your treatment or diagnosis may be considered “Highly Conﬁdential Information” and as a result will not be disclosed to your parent or guardian without your consent and/or authorization. Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered. Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notiﬁcation.
You have certain rights under federal and state privacy standards. These include:
- The right to revoke your authorization (or consent) to our use of your medical information as long as you make your request in writing to the Compliance Ofﬁcer at the address below. You can revoke your authorization (or consent) for future disclosures but not for any disclosures made prior to when you ﬁrst gave your authorization (or consent).
- The right to request restrictions on the use and disclosure of your medical information, as long as the restriction you request is not prevented by We will consider your request but are not required to accept it (with one limited exception relating to disclosures to a health plan where you pay out of pocket in full for the health care item or service).
- The right to make a reasonable request for conﬁdential communications concerning your medical condition and
- The right to inspect and copy your medical records and billing records. To the extent that electronic health records are available, you have a right to an electronic copy of your record, and, if you choose, to direct us to transmit a copy of the electronic health record to a designated individual or As permitted by federal regulation, we require that requests to inspect or copy your medical records and/or billing records be submitted in writing.
- The right to request an amendment or submit corrections to your medical information, as long as we created the information and changes would not make the medical record inaccurate or incomplete.
- The right to receive a list of how and to whom certain of your medical information has been disclosed, called an “accounting of disclosures.” A request for such an accounting may not date back more than six years. We require a request for an accounting to be submitted in writing. To the extent that we use or maintain your medical information in an electronic designated record set, you also have a right to receive an access report indicating who has accessed such information (including access for purposes of treatment, payment, and health care operations) during a period of time up to three years prior to the date of your request. We will provide an access report relating to such disclosures made by us and all of our Business Associates. We require a request for an access report to be submitted in
- The right to receive a breach notiﬁcation that complies with applicable Federal and State laws and regulations in the event of a breach of your unsecured protected health information.
- The right to receive a printed copy of this notice.
Requests to Inspect Medical Information, Receive an Accounting or Access Report of Disclosures or Revoke Your Consent (or Authorization). You may be charged a fee for processing your request to copy your medical information or receive an accounting or access report of disclosures. You may obtain a form to request access to your records, request an accounting or access report of disclosures, or revoke your consent (or authorization) by writing to:
Cape Cod Eye Surgery and Laser Center 282 Route 130
Sandwich, MA 02563
Complaints and Contact Person
If you would like to submit a comment or complaint about our privacy practices, or obtain additional information about our privacy practices, you can do so by sending a letter outlining your concerns to the person listed below. You may also contact the Secretary of the Department of Health and Human Services at the address below. You will not be penalized or otherwise retaliated against for ﬁling a complaint.
Ellen Adams, MBA Ofﬁce for Civil Rights
Compliance Ofﬁcer Department of Health and Human Services
50 Staniford Street Attn: Patient Safety Act
Boston, MA 02114 200 Independence Ave., SW, Rm. 509F
800-635-0489 Washington, D.C. 20201
617-367-4800 email: firstname.lastname@example.org
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices, including this notice of privacy practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. The revised policies and practices will be applied to all medical information that we maintain.
This revised notice is effective as of July 17, 2013. The original notice was adopted as of April 14, 2003.