GATEWAY EYE ASSOCIATES, PC
2 Gateway Center
Pittsburgh, PA 15222
PH:(412) 471-9838
FAX:(412) 471-9849

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.

We understand that your personal health information is confidential. This Notice, effective April 14, 2003, describes how we use, disclose and protect your health information and explains your rights regarding your Personal Health Information. We are required by federal law to keep your Personal Health Information private; give you this Notice of our legal duties and privacy practices and policies; and to abide by the terms of the Notice that are currently in effect.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
In performing our duties, the most common reason why we use or disclose your personal health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up appointments for you; reminders of existing appointments; your professional eye health examinations; assisting you with eyewear selection; prescribing / writing / phoning / faxing prescriptions for eyeglasses, contact lenses or medications to be filled; referring you to another doctor or clinic for further care; or getting copies of your health information from a professional you may have seen before us. Examples of how we use or disclose your personal health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; determining your eligibility, authorization and plan benefits for your insurance; preparing and sending bills, claims or explanations of benefits; collecting payments (either ourselves or through a collection agency or attorney); or investigating insurance claims. Health care operations are administrative, managerial and research activities that we have to do to run our office. Examples of how we use or disclose your personal health information for health care operation are: financial or billing audits; internal quality assurance / reviews; personnel decisions; investigation and defense of legal matters; business planning; and ourside storage of our records.

ADDITIONAL USES AND DISCLOSURES WITHOUT PERMISSION
In some limited situations, the law allows and requires that we use or disclose your health information without your permision. Such uses and disclosures are:

• when a state or federal law mandates that certain health information be reported for a specific purpose;
• for public health and safety purposes, such as contagious disease reporting, investigation or surveillance, notification of product recall notices by Food and Drug Adminstration regarding drugs or medical devices, disaster relief efforts or national security;
• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
• uses and disclosures for health oversight activities, such as for the licensing of doctors, or for audits by Medicare or Medicaid or for investigations of possible violations of health care laws;
• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to provide information about a crime at our office, or to report a crime that occurred somewhere else;
• disclosures to a coroner or medical examiner to identify a dead person or determine cause of death, to funeral directors to aid in burial, or to organizations that handle organ and tissue donation;
• disclosures to the military as required by military command authorities if you are serving in the military;
• uses and disclosures for health related research;
• disclosures for judicial and admininstrative proceedings, such as in response to court orders or subpeonas;
• disclosures to contractors who are our business associates and who are required and committed to respect and to protect your personal healt information;
• disclosures for specialized government functions, such as for the protection of the president or high ranking government officials, for lawful national intelligence activities, or for the evaluation and health of members of the foreign services;
• disclosures of de-identified information;
• disclosures related to workers compensation programs;

   

  DISCLOSURE AT YOUR REQUEST
  We may only use or disclose your personal health information as described in this notice or according to laws that apply to us. Other uses or disclosures of your health information will be made only with your written authorization. The content of an authorization form is determined by federal law. If we initiate the process, you do not have to sign the authorization form, and if so, we will not make the use or disclosure. Once authorization is given, you may revoke that permission at any time by written request to our office. If you revoke your permission, we will no longer use or disclose your personal health information for the reasons stated in your authorization, except to the extent that we have already acted in reliance to the authorization.

  DISCLOSURE TO CAREGIVERS
  Unless you object, we may use or disclose relevant personal health information to a family member, your personal representative or another person involved in your care to the extent necessary to help with your care or with payment for your care. For example, we may allow a person to pick up your eyeglassed, contact lenses, medical supplies or copy of your prescription or health records.

  APPOINTMENT AND RECALL REMINDERS
  Our office may contact you, either directly or through a business associate, to remind you to schedule an appointment with us. The appointment reminder contact may include marketing materials from various manufacturers or suppliers for products or services that are of interest to you. In addition, our office may contact you, either directly or through a business associate, to provide information about treatment alternatives or other health related benefits or services that may be of interest to you. Unless you tell us otherwise, we will mail you an appointment reminder and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not at home.

  YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION
  Your rights regarding your personal health information are:

• Right to Inspect and Copy. You have the right to inspect and copy your personal health information that we maintain. If you request a copy of the information, we will charge you an administrative fee for the costs of copying, mailing or other supplies and fees associated with your request.
• Right to Amend. You have the right to amend your personal health information if you feel that we have incorrect of incomplete information. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, the current information is accurate and complete or if we did not create the information. If we deny your request, you may send us a written notice of disagreement with our denial.
• Right to an Accounting of Disclosures. You have the right to request a list of our disclosures for purposes other than treatment, payment or healthcare operations or disclosures made to you or your representatives, authorize by you, or made to law enforcement personnel. Your request must state a time period and may not include dates before April 14, 2003. If you request more than one list in a year, we will charge you for the costs of providing a list. We will notify you of the costs involved and you may change your request at that time before any costs are incurred.
• Right to Request Restrictions. You have the right to request that we restrict the way we use or disclose your personal health information regarding treatment (except emergency treatment), payment or healthcare operations. You also have the right to request that we restrict the personal health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. Restrictions must be a written request to the office. We are not required to agree to your request.
• Right to Request Confidential Communication. You have the right to make a reasonable request that we communicate personal health information to you in a certain way or at a certain address. Your request must specify how or where you wish to be contacted. We will comply with reasonable requests and with any additional costs billed to you.
• Right to a Paper Copy. You have the right to receive this notice in written form and you may request from us additional paper copy of this notice at any time.

   

  CHANGES TO THIS NOTICE
  We reserve the right to change the terms of this Notice of Privacy Practices at any time as allowed by law. If we make any such changes, the new terms and policies will apply to all personal health information that we currently have and receive in the future. If we change this notice, we will post the new Notice of Privacy Practices in our office and have copies available in our office.

  COMPLAINTS
  If you believe your privacy rights have been violated, you have the right to file a complaint with Gateway Eye Associates. Complaints can be submitted in writing to:
  Gateway Eye Associates
  2 Gateway Center
  Pittsburgh, PA 15222
  \t
  \t\t\t\t
  -----------Attention: Privacy Officer-------------
  You must include your include your name, address, telephone number and a detailed description of the complaint. We will conduct a reasonable and logical investigation of the violation. If you prefer, you can discuss your complaint in person or by phone. You may also contact the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights, with your complaint.

  FOR MORE INFORMATION
  For more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

  HIPAA PRIVACY
  ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
  I acknowledge that I received a copy of Gateway Eye Associate's Notice of Privacy Practices.

  PATIENT NAME_______________________________________________ DATE__________________________________________________________________ DATE____________________________

  SIGNATURE

  REFUSAL OF ACKNOWLEDGEMENT
  Patient or Patient's legal representative refused to sign or is unable to sign acknowledgement of receipt of notice.

  PROVIDER/ASSOCIATE NAME

  SIGNATURE