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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.
Casco Bay EyeCare, L.L.C. Duties
We are required by law to maintain the privacy of your protected health
information and to provide you with this notice of privacy practices. We
are also required to abide by the privacy policies and practices which are
currently in effect and that are outlined in this notice or in any amendment
to this notice.
Protected health care information includes information regarding your past,
present or future physical or mental health or condition, the health care
and services provided to you, and the past, present or future payment for
your health care.
WAYS IN WHICH WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION.
Treatment.
Your health information may be used by our physicians and staff members
or may be disclosed to other health care professionals for the purposes
of evaluating your health, diagnosing medical conditions, and providing
treatment.
Payment.
Your health information may be used to seek payment from your health plan,
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.
Health care operations.
Your health information may be used as necessary to support the day-to-day
activities and management of Casco Bay EyeCare, L.L.C. For example, information
on the services our patients receive may be used 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 health care information.
Family Members or Other Persons Involved in Your Care.
Your health information may be disclosed to a family member, other relative,
close friend or other person you identify. Disclosures will be limited to
your health information that is relevant to such family member or other
person's involvement in your care or payment for your care. If you are present,
your health information will be disclosed if: (i) we obtain your agreement,
(ii) we provide you with an opportunity to object and you do not object,
or (iii) we reasonably assume you do not object. If you are not present
or you do not have an opportunity to object or agree because you are incapacitated
or it is an emergency, we may make disclosures that, in our professional
judgment, are in your best interest.
Required by Law or Law Enforcement.
We will disclose your health information when required by federal, state
or other applicable law. Your health information may also 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, we will disclose your health information
on the request of a law enforcement official if you are or are suspected
to be a victim of a crime and we are unable to obtain your authorization
to disclose your health information.
Funeral Director.
Your health information may be disclosed to funeral directors as necessary
for them to provide services.
Public Health Reporting.
Your health information may be disclosed to public health agencies as required
by law. For example, our practice is required to report certain communicable
diseases to State of Maine Department of Health.
Organ Donation.
If you are an organ donor, your health information may be disclosed to organizations
that engage in the procurement, banking or transportation of organs, eyes
or tissues for transplantation or donation.
Workers' Compensation.
Your health information may be disclosed as authorized by and to the extent
necessary to comply with laws relating to workers' compensation or similar
programs that provide benefits for work-related injuries.
Judicial and Administrative Proceedings.
Your health information may be disclosed to comply with a court or administrative
order. In addition, your health information may be disclosed to comply with
a subpoena, discovery request or other lawful process that is not accompanied
by a court order if (i) we receive satisfactory assurances that reasonable
efforts have been made to ensure that you have been given notice of the
request, or (ii) we receive satisfactory evidence that reasonable efforts
have been made to secure a qualified protective order.
Health Oversight.
Your health information may be disclosed to a health oversight agency for
oversight activities authorized by law such as audits, civil, criminal or
administrative investigations, inspections, licensure, disciplinary actions
and other activities for oversight of our healthcare system.
Military Personnel.
If you are a member of the armed forces, your health information may be
disclosed as required by the military.
National Security.
Your health information may be disclosed to authorized federal officials
for the conduct of lawful intelligence, counter-intelligence and other national
security actions.
Inmates.
If you are an inmate of a state or local prison, or under custody of a law
enforcement official, we may disclose your health information to the facility
or law enforcement office to provide you with health care, to protect your
health and safety and to protect the health and safety of other inmates,
officers, and employees of the correctional facility or law enforcement
office.
Additional uses of information.
Appointment reminders.
Your health information will be used by our staff to call and/or send you
appointment reminders. These may take the form of messages left on an answering
machine, letters or post cards.
Information about treatments.
Your health information may be used to send you information on the treatment
and management of your medical condition that you may find to be of interest.
We may also send you information describing other health-related goods and
services that we believe may interest you.
Other authorized uses and disclosures.
You may authorize us to use and disclose your health information for purposes
other than those listed above. Your authorization must be in writing and
must comply with applicable law. If you change your mind after authorizing
a use or disclosure of your information, you may submit a written revocation
of the authorization. However, your decision to revoke the authorization
will not affect or undo any use or disclosure of information that occurred
before you notified us of your decision.
Individual Rights.
You have certain rights under the federal and state privacy standards. These
include:
Right to Request Restrictions.
You have the right to request restrictions on our use and disclosure of
your protected health information for purposes of treatment, payment or
health operations. For example, you may request that we not disclose your
health information to a family member involved in your care. Your request
to restrict the use and disclosure of your health information should be
in writing and should be sent to our Compliance Coordinator. The request
must state (i) what health information you do not want used or disclosed,
(ii) whether you want to limit our use, limit our disclosure, or both, and
(iii) the names of persons or entities to whom disclosure should not be
made. We are not required to comply with your request. If we do agree to
comply, we may terminate our agreement to restrict use or disclosure of
your health information. Such termination will be effective only for health
information created or received after the termination.
Right to Confidential Communications.
You have the right to receive confidential communications concerning your
medical condition and treatment. For example, you have the right to request
that we communicate your health information to you at an alternate address
or by alternate means. Your request should be in writing and should be sent
to our Compliance Coordinator.
Right to Inspect and Copy.
You have the right to inspect and copy your health information. If you would
like a copy of your health information, you should request an authorization
form from the supervisor of our office or the Compliance Coordinator. You
will be charged for our reasonable costs of copying and mailing. We may
deny your request in certain circumstances. For example, we may deny your
request if we conclude that access to your health information will endanger
your life or physical safety. If we deny your request, you may request,
in a written document sent to the Compliance Coordinator, that the denial
be reviewed.
Right to Correct or Clarify.
You have the right to request an amendment to or submit corrections to your
health information. The information you desire to submit should be in writing
and should be sent to the Compliance Coordinator. The information you submit
will be retained with our records of your treatment. If we add a statement
to your treatment record in response to your submission, we will provide
you with a copy of the statement.
Right to Accounting of Disclosures.
You have the right to receive a written accounting of certain disclosures
we make of your health information. Your request for an accounting should
be in writing and should be sent to our Compliance Coordinator. The request
should state the period for which you are requesting the accounting but
cannot exceed six (6) years. We may charge you for the cost of preparing
the accounting. The accounting will include the date of each disclosure,
the name and, if known, address of the person or entity receiving the disclosure,
a brief description of the information disclosed and a brief statement of
the purpose of the disclosure. We do not provide an accounting of the following
disclosures: (i) disclosures for treatment, payment or health care operations,
(ii) disclosures made to you, (iii) disclosures made to persons involved
in your care, (iv) disclosures authorized by you, (v) disclosures for national
security or intelligence purposes, (vi) disclosures to correctional institutions
or law enforcement officials, and (vii) disclosures made prior to April
14, 2003.
Right to Receive a Printed Copy of this Notice.
You have the right to receive a printed copy of this notice.
Right to Revise Privacy Practices.
As permitted by law, Casco Bay EyeCare, L.L.C. reserves the right to amend
or modify its privacy policies and practices. These changes in our policies
and practices may be required by changes in federal and state laws and regulations.
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 Web
site. The revised policies and practices will be applied to all protected
health information that we maintain.
Personal Representatives.
There are times when individuals are legally or otherwise incapable of exercising
their privacy rights, or chose to designate someone to act on their behalf.
A person authorized to act on behalf of another individual is the individual's
"personal representative". A personal representative may have broad authority
to make health care decisions for an individual. Or, a personal representative's
authority may be limited to specific treatment or care. For example, a legal
guardian may have broad authority while a person with an individual's limited
health care power of attorney may have only have authority regarding a specific
treatment.
The following table identifies who will be recognized as the personal representative
for a category of individuals:
| Individual | Personal Representative |
| Unemancipated Minor | A
parent, guardian or other person authorized by State law to make health
care decisions on behalf of the minor child See exceptions below |
| Adult or emancipated minor | A
person with legal authority to make health care decisions on behalf
of the individual. Examples:
|
| Deceased individual |
A person with legal authority to act on behalf of the decedent's estate. Example:
|
Regardless of whether a parent is the personal representative of a minor
child, under certain circumstances we are prohibited from disclosing the
child's health care information to the parent. We cannot disclose a minor
child's health information to a parent under the following circumstances:
- When State or other law does not require the consent of a parent
or other person before a minor can obtain a particular health care service,
and the minor consents to the health service.
- When a court determines or other law authorizes someone other than a parent
to make treatment decisions for a minor.
- When a parent agrees to a confidential relationship between the minor and
our physician.
Under certain circumstances we may chose not to recognize a person as the
personal representative of our patient. For example, if we believe that
a minor child or incompetent adult has been or may be subjected to domestic
violence, abuse or neglect by a personal representative, or that treating
a person as the minor child's or incompetent adult's personal representative
could endanger the child or adult, we may choose not to treat the person
as the personal representative if, in our professional judgment, doing so
would not be in the best interest of the minor child or incompetent adult.
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 will not be penalized or otherwise retaliated against for filing a complaint.
Kim Thorne
Compliance Coordinator
Casco Bay EyeCare, L.L.C.
P.O. Box 7487
Portland, Maine 04112
207-885-8686
You may also send a complaint to the Secretary of Health and Human Services
if you feel that your privacy rights have been violated.
Effective date
This notice is effective on or after April 14, 2003.