Privacy Notice

NOTICE OF PRIVACY PRACTICES - GEORGIA RETINA, P.C.

EFFECTIVE DATE OF PRIVACY NOTICE: April 14, 2003

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.

If you have any questions about this notice, please contact: Jeff Gorke, Administrator, Georgia Retina, P.C., 575 Professional Drive, Suite 330, Lawrenceville, GA, 30045, 678.405.0922.

I. OUR GENERAL DUTIES REGARDING YOUR MEDICAL INFORMATION

We receive, use and create medical information and records related to the care and services you receive at Georgia Retina, P.C. ("Practice"). We need such information to provide you with quality care, to comply with certain legal requirements, and to carry out business functions of the Practice. We are required by law to maintain the privacy of your medical information (also known as "protected health information"). In other words, we must make sure that medical information that identifies you is kept private. We are committed to protecting your privacy rights, and will only use or disclose your medical information as permitted by law.

This Notice applies to all of the records of your care used or generated by this Practice and describes the different ways that we use and disclose your medical information. It also describes certain rights that you have with respect to your medical information. We are required by law to give you this Notice of our legal duties and privacy practices with respect to medical information about you. You have the right to receive a paper copy of this Notice. In addition, if we maintain an Internet Web Site, we will make a copy of our current Notice available on that Site.

We are required by law to abide by the terms of the Notice that is currently in effect. Please be aware that we may change the terms of this Notice at any time. We will post a copy of the current notice in the office waiting area. In addition, each time you visit our office for treatment, we will make a copy of the current notice in effect available to you upon your request.

II. USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

A. Frequent and Routine Uses and Disclosures for Treatment, Payment, Health Care Operations, and Administrative Purposes.

At your first face-to-face visit to our offices on or after April 14, 2003 , we will use good faith efforts to obtain from you a written acknowledgment that you have received a copy of this Notice of Privacy Practices. After that, with a very few exceptions described below, applicable Georgia and Federal (HIPAA) laws permit us to use and disclose your medical information for treatment, payment and/or health care operations purposes and other routine uses, as described below.

• No Consent Needed: We are not required to obtain your consent to use/disclose your patient information for the following purpose(s):
  • Treatment — We may use or disclose medical information about you to provide you with medical treatment or services. This means that we may share medical information about you with doctors, nurses, and other staff here at the Practice who are involved in taking care of you. It also means that we may disclose medical information about you to providers outside our office who are or may be involved in your medical care. For example, we may disclose medical information to another physician, a hospital, surgical center or other facility to which we may send you for procedures or follow-up care.
  • Appointment Reminders and Other Administrative Purposes — We may also use and disclose medical information about you to:
    • Contact you as a reminder that you have an appointment for treatment at the Practice (but this may be limited by your request for confidential communications, as described below on page 6);
    • Tell you about or recommend possible treatment options or alternatives that may be of interest to you; and
    • Tell you about health-related benefits or services that may be of interest to you.
  • For Payment — We may use or disclose medical information about you to your insurance company, a governmental payer or other responsible third party for the purpose of receiving payment for the medical treatment you have received. For example, we may tell your health plan about a medical treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also use your medical information for billing and collections purposes
  • For Health Care Operations — We also may use and disclose medical information about you for purposes of health care operations. These uses and disclosures are for the necessary business of the Practice, and they include such activities as education and training and quality improvement. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. For some of these health care operations purposes, we will share your medical information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the Practice. Whenever an arrangement between our Practice and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
• Exceptions — Georgia law gives certain types of medical information more stringent confidentiality protection. Ordinarily, because of the nature of our Practice, we do not have occasion to access, use or disclose such information. If we do use such information, however, our practices are as follows.
  • AIDS/HIV — For purposes other than patient treatment, public health and safety and compliance with a court order, we must obtain your specific authorization before we disclose information about HIV/AIDS status or testing results. Thus, for example, we must obtain specific authorization from you before releasing any such information about you for payment or health care operations purposes, but we do not have to do so for treatment purposes.
  • Mental Health Records — For clinical records pertaining to mental health, disclosure is prohibited absent your specific authorization except where the information is disclosed i) for treatment, ii) upon the admission of a patient to or transfer of the patient from a facility, iii) to the patient's attorney, iv) in a medical emergency, v) pursuant to a court order, vi) for use in the course of a study for the purpose of reducing the rates of morbidity and mortality, and vii) to a law enforcement officer in the course of investigating the commission of crime on the premises of, or against personnel of, a treatment facility [a].
  • Drug and Alcohol Treatment — For clinical records pertaining to alcohol or drug abuse treatment, disclosure is prohibited absent your specific authorization except where such information is disclosed i) for treatment, ii) upon the transfer of the patient, iii) to the patient's attorney, iv) in a medical emergency, v) pursuant to a court order, vi) to a law enforcement officer in the course of a criminal investigation [b], and vii) to a law enforcement officer in the course of investigating the commission of crime on the premises of, or against personnel of, a mental health facility.
  • Genetic Testing — Information derived from genetic testing performed on you is confidential and may be released only to you (the individual tested) and to persons specifically authorized by you to receive the information. However, such information may be disclosed without your authorization where the information regards the identity of any individual who is the subject of a criminal investigation or a criminal prosecution. Further, any research facility may conduct genetic testing and may use the information derived from genetic testing for scientific research purposes so long as the identity of any individual tested is not disclosed to any third party (other than the individual's physician).

B. Other Uses and Disclosures of Medical Information for which Patient Permission or Authorization is Not Necessary

We may use and disclose medical information without your express permission in the following situations:

• Uses and Disclosures to Family and Friends — We may disclose to your family member, or close personal friend involved with your medical care, medical information about you that is directly relevant to your family member or friend's involvement with your care or with the payment related to your care. In most instances, before we disclose any medical information about you to your family members or your friends, we will inform you of the disclosure and give you an opportunity to agree or object to the disclosure.
• Uses and Disclosures for Disaster Relief Purposes — For the limited circumstances of disaster relief efforts, we may disclose medical information about you to your close family or friends, or to a public or private disaster relief entity for purposes of notifying your family and friends of your condition and location. If you are available and competent, prior to the disclosure we will give you an opportunity to agree or object to the disclosure to the extent that providing you with prior notice and an opportunity to restrict or object to the disclosure will not interfere with our ability to respond to the emergency situation.
• Uses and Disclosures Required by Law — We may use or disclose medical information to the extent that such use or disclosure is required by federal, state, or local law and the use or disclosure complies with and is limited to the relevant requirements of such law;
• Uses and Disclosures for Public Health Activities — We may use or disclose medical information about you for public health activities, such as to:
  • a public health authority that is authorized by law to collect or receive information for the purposes of preventing or controlling disease, injury, or disability;
  • or to a public health authority or other appropriate government entity authorized by law to receive reports of child abuse or neglect;
  • an FDA agent or official to report reactions to medication or problems with products;
  • a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or
  • an employer, to evaluate whether the individual has a work-related illness.
• Disclosures about Victims of Abuse, Neglect or Domestic Violence — We may disclose medical information about you to a government authority, including a social service or protective agency if we reasonably believe a patient to be a victim of abuse, neglect, or domestic violence.
• Uses and Disclosures for Health Oversight Activities — We may disclose or use medical information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; or licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
• Disclosures for Judicial and Administrative Proceedings — We may disclose medical information about you in the course of any judicial or administrative proceeding with a valid court order or appropriate subpoena or discovery request, so long as we follow certain procedures required by Georgia or federal law.
• Disclosures for Law Enforcement Purposes — We may disclose medical information if asked to do so by a law enforcement official, so long as we follow certain procedures required by Georgia or federal law.
• Uses and Disclosures to Coroners, Medical Examiners and Funeral Directors — We may release medical information to a coroner or medical examiner for the purpose of identifying a deceased person, determining the cause of death, or other duties as authorized by law. We may also release medical information to funeral directors as necessary to carry out their duties.
• Uses and Disclosures for Organ, Eye or Tissue Donation Purposes — We may use or disclose medical information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye, or tissue donation and transplantation.
• Uses and Disclosures for Research Purposes — We may use or disclose medical information about you for research purposes, if we follow a special approval process. This process evaluates a proposed research project and its use of medical information, specifically trying to balance the research needs with patients' needs for privacy of their medical information. If we do not complete this approval process, we will not use or disclose medical information for research without your Authorization.
• Uses and Disclosures to Avert a Serious Threat to Health or Safety — We may use or disclose (and sometimes Georgia law requires us to use or disclose) medical information about you if we reasonably believe, in good faith, that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of you or any other person.
• Uses and Disclosures for Specialized Government Functions — We may use or disclose medical information of individuals who are Armed Forces personnel, to authorized federal officials for national security and intelligence purposes and for protection of the President of the United States or other heads of state. In some circumstances, we may use or disclose medical information about an inmate or individual that the correctional institution has lawful custody of.
• Uses and Disclosures for Workers' Compensation — We may disclose medical information as authorized by and to the extent necessary to comply with Georgia's laws relating to workers' compensation.

C. Uses and Disclosures With Your Authorization Only

A use and disclosure of medical information for purposes not listed above in Sections A and B, including most marketing purposes, will only be made with the your written Authorization. The Authorization form that we use complies with applicable laws. You may revoke this Authorization at any time by providing us with written notice of such revocation. Your revocation shall become effective immediately upon our receipt of such notice, except to the extent that we have already relied upon your previous Authorization.

III. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with this Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Secretary of the Department of Health and Human Services, contact Medical Privacy, Complaint Division, Office of Civil Rights, United States Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201; Voice Hotline Number (800) 368-1019; Internet Address www.hhs.gov/ocr.

To file a compliant with the Practice, contact Jeff Gorke, Administrator, Georgia Retina, P.C., 575 Professional Drive, Suite 330, Lawrenceville, GA 30045

All complaints must be submitted in writing.

You will not be penalized in any way for filing a compliant.

http://www.garetina.com/privacy.cfm