Van Hoose Optometric Corporation

7246 Clairmont Mesa Blvd., San Diego CA 92111 

858-292-7193 www.avveye.com

Marc Van Hoose, Privacy Official

Effective Date: 

We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices and abide by the policies in it. 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 reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not.

Examples of how we might use or disclose health information for treatment purposes might include:

• Setting up or changing      appointments including leaving messages containing no information about      your personal health information with those at your home or office who may      answer the phone or leaving messages on answering machines, voice mails,      text or email; 
• calling your name out in a      reception room environment; 
• prescribing glasses, contact      lenses, or medications as well as relaying this information to suppliers      by phone, fax or other electronic means including initial prescriptions      and requests from suppliers for refills; 
• notifying you that your      ophthalmic goods are ready, including leaving messages containing no      personal health information with those at your home or office who may      answer the phone, or leaving messages on answering machines, voice mails,      text or emails; 
• referring you to another doctor      for care not provided by this office; 
• obtaining copies of health      information from doctors you have seen before us; discussing your care      with you directly or with family or friends you have inferred or agreed      may listen to information about your health; 
• sending you postcards or      letters or leaving messages containing no personal health information with      those at your home who may answer the phone or on answering machines,      voice mails, text or emails reminding you it is time for continued      care; 
• at your request, we can provide      you with a copy of your medical records via secured fax, secured email,      secured patient portal, or printed copies delivered in person or through      the US mail.

Examples of how we might use or disclose health information for payment purposes might include:

• Asking you about your vision or      medical insurance plans or other sources of payment; 
• preparing and sending bills to      your insurance provider or to you; 
• providing any information      required by third party payors in order to ensure payment for services      rendered to you; 
• sending notices of payment due      on your account to the person designated as responsible party or head of      household on your account with fee explanations that could include      procedures performed and for what diagnosis: collecting unpaid balances      either ourselves or through a collection agency, attorney, or district      attorney's office. At the patient's request we may not disclose to a health plan      or health care operation information related to care that you have paid      for out of pocket. This only applies to those encounters related to the      care you want restricted and only to the extent a disclosure is not      otherwise required by law.

Examples of how we might use or disclose health information for business operations might include:

• Financial or billing      audits; 
• internal quality assurance      programs; participation in managed care plans; defense of legal      matters; 
• business planning; 
• certain research functions;      informing you of products or services offered by our office; 
• compliance with local, state,      or federal government agencies request for information; 
• oversight activities such as      licensing of our doctors; 
• Medicare or Medicaid      audits; 
• providing information regarding      your vision status to the Department of Public Safety, a school nurse, or      agency qualifying for disability status

Uses and Disclosures for Other Reasons Not Needing Permission

In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could.

• When a state or federal law      mandates that certain health information be reported for a specific      purpose
• For public health reasons, such      as reporting of a contagious disease, investigations or surveillance, and      notices to and from the federal Food and Drug Administration regarding      drugs or medical devices
• Disclosures to government or      law authorities about victims of suspected abuse, neglect, domestic      violence, or when someone is or suspected to be a victim of a crime
• Disclosures for judicial and      administrative proceedings, such as in response to subpoenas or orders of      courts or administrative hearings
• Disclosures to a medical      examiner to identify a deceased person or determine cause of death or to      funeral directors to aid in burial
• Disclosures 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 of an individual or individuals
• Uses or disclosures to aid      military purposes or lawful national intelligence activities
• Disclosures of de-identified      information
• Disclosures related to a      workman's compensation claim
• Disclosures of a "limited      data set" for research, public health, or health care operations
• Incidental disclosures that are      an unavoidable by-product of permitted uses and disclosures
• Disclosure of information      needed in completing form from a school related vision screening,      information to the Department of Public Safety (driver's license),      information related to certification for occupational or recreational      licenses such as pilots license.
• Disclosures to business      associates who perform health care operations for Ackroyd & Van Hoose      Optometry and who commit to respect the privacy of your information. We      also require any business associate to require any sub-contractor to      comply with our privacy policies.
• Unless you object, disclosure      of relevant information to family members or friends who are helping you      with your care or by their allowed presence cause us to assume you approve      their exposure to relevant information about your health.

Uses or Disclosures To Patient Representatives

It is the policy of Van Hoose Optometric Corporation for our staff to take phone calls from individuals on a patients behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Van Hoose Optometric Corporation staff will also assist individuals on a patient's behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient's vision or health status may be disclosed without proper patient consent. Van Hoose Optometric Corporation staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual.

Other Uses and Disclosures

We will not make any other uses or disclosures of your health information or uses and disclosures involving marketing unless you sign a written Authorization for Release of Identifying Health Information. The content of this authorization is determined by applicable state and federal law. The request for signing an authorization may be initiated by Van Hoose Optometric corporation or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may decline to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to the Privacy Officer named at the beginning of this Notice.

Your Rights Regarding Your Health Information

The law gives you many rights regarding your personal health information.

• You may ask us to restrict our      uses and disclosures for purposes of treatment (except in emergency care),      payment, or business operations. This request must be made in writing to      Privacy Officer named at the beginning of this Notice. We do not have to      agree to your request, but if we agree, must honor the restrictions you      ask for.
• You may ask us to communicate      with you in a confidential manner. Examples might be only contacting you      by telephone at your home or using some special email address. We may      accommodate these requests if they are reasonable and if you agree to pay      any additional cost, if any, incurred in accommodating your request.      Requests for special communication requests must be made to the Privacy      Officer named at the beginning of this Notice.
• You may ask to review or get      copies of your health information. For the most part we are happy to      provide you with the opportunity to either review or obtain a copy of your      medical information, but rare situations may restrict release of the      information. In such cases we will provide you such denial in writing.      Another licensed health care practitioner chosen by Van Hoose Optometric Corporation      may review your request and our denial. In such cases we will abide by the      outcome of that review. We ask that requests for review or copy of medical      information be made in writing to the Privacy Officer named at the      beginning of this Notice, but this is not a requirement. While we usually      respond to these requests in just a day or so, by law we have a short      period of time specified by State or Federal law to respond to your      request. We may request an additional extension of time in certain      situations.
• Health care information you      request copies of may be delivered to you in the format you request. The      e-formats Van Hoose Optometric Corporation has approved include secure      email, an authorized Electronic Health Information system and media      supplied by Van Hoose Optometric Corporation.
• You may ask us to amend or      change your health care information if you think it is incorrect or      incomplete. If we agree, we will make the amendment to your medical record      within thirty (30) days of your written request for change sent to the      Privacy Officer named at the beginning of this Notice. We will then send      the corrected information to you or any other individual you feel needs a      copy of the corrected information. If we do not agree, you will be      notified in writing of our decision. You may then write a statement of      your position and we will include it in your medical record along with any      rebuttal statement we may wish to include.
• You may request a list of any      non-routine disclosures of your health information that we might have made      within the past six (6) years. Routine disclosures would include those      used your treatment, payment, and business operations of Van Hoose Optometric      Corporation. These routine disclosures will not be included in your list      of disclosures. You are entitled to one such list per year without charge.      If you want more frequent lists, you must pay for them in advance at a fee      of $250 per list. We will usually respond to your written request (made to      the Privacy Officer      named at the beginning of this Notice) within thirty (30) days but we are      allowed one thirty (30) day extension if we need the time to complete your      request.
• You may obtain additional      copies of this Notice of Privacy Practices from our business office or      online at our website address shown at the beginning of this Notice.

Breach Notification Policy

In the event of a reportable breach of patient information, Van Hoose Optometric Corporation agrees to abide by the breach notification requirements as established by the HIPAA Breach Notification Rule or specific State requirement. If a breach occurs, Van Hoose Optometric Corporation will take all necessary steps to remain in compliance with this rule including as applicable notification of individuals, Business Associates, the Secretary of Health and Human Services and prominent media outlets.

Whistleblower Protection Rule 

Van Hoose Optometric Corporation will take no action against any individual who provides information to the Office of Civil Rights, Office of the Inspector General or individual state Attorney General's Office regarding concerns related to the privacy and security procedures or actions at Van Hoose Optometric Corporation.

Changing Our Notice of Privacy Practices

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time. If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website.

Complaints

If you think that anyone at Van Hoose Optometric Corporation has not respected the privacy of your health information, we encourage you to discuss your concerns with the Privacy Officer named at the beginning of this Notice. We request you submit your concerns in writing. We are more than happy to try to resolve any concern you may have. We want to resolve your concerns but you may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the state Attorney General's Office. We will not retaliate against you if you make such a complaint. 

Questions

If you have any questions or concerns we encourage you to contact the Privacy Officer at the