Carolina Retina Center

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.

If you have any questions about this Notice, please contact our Privacy Officer at (803) 736-7200 or email@carolinaretinacenter.com

Effective date: April 14, 2003

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We require all of our employees, staff and independent contractors to comply with these privacy practices.

Please sign the attached Acknowledgement Form and return it to the staff at the front desk.

1. The Use and Disclosure of Medical Information for Treatment, Payment and Health Care Operations: By law we are allowed to use and disclose your medical information for most purposes related to your medical treatment ("Treatment"), the payment of your medical treatment ("Payment"), and our health care operations or the operations of other covered entities to whom we disclose your medical information ("Operations").

Treatment means the provision, coordination or management of health care and related services by or involving one or more health care providers, such as the coordination of consultations and referrals. For example, we can share most medical information regarding your health condition with another provider as part of a consultation.

Please note that by law, certain medical information, such as psychotherapy notes, generally may not be used or shared even when it is related to treatment, unless an authorization form is obtained from you to use or release that information.

Payment means activities related to obtaining reimbursement from HMO's, insurers or other payers for services provided to you. Payment can also cover activities to determine your eligibility for services with your insurer, coordination of benefits with other insurers, billing, claims management, collection, medical necessity review activities, utilization review activities and disclosure to consumer reporting agencies. For example, we can disclose to your health plan medical information that is required by the plan to determine whether the services we have provided to you are medically necessary or obtaining approval for surgery may require that your relevant protected health information be disclosed to the health plan.

Healthcare Operations cover a range of activities. We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, training staff and conducting or arranging for other business activities.

For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may also contact you to remind you to make an appointment; remind you of an appointment; to notify you regarding treatment alternatives or other health-related benefits and services that may be of interest to you.

We will share your protected health information with third party "business associates" that perform various activities, .e.g, billing service, transcription service, or engaging counsel to defend us in a legal action is another activity that is considered health care operations for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Uses and Disclosures of Protected Health Information Based upon your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. An authorization is a written permission that specifically identifies the information that we will use or disclose, and when and how we will use or disclose it. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Uses and Disclosures of Medical Information Without Your Consent or Authorization

If You Don't Object Verbally. Under certain circumstances, we may use or disclose your medical information without an authorization or other written permission from you if we give you the opportunity to agree or object verbally. These circumstances are as follows:

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Uses and Disclosures of Medical Information Without Your Authorization or Opportunity to Agree or Object Verbally. In the following situations we are permitted under law to use or disclose your medical information without obtaining your consent or authorization or allowing you to agree or object.

Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is authorized by law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may be asked or required by law to divulge protected health information to a public health authority under the following circumstances: i) to report a birth, death, disease or injury; ii) a part of a public health investigation; iii) to report child or adult abuse or neglect, or domestic violence as authorized by law; iv) to report adverse events (such as product defects), to track products or assist in product recalls or repairs or replacements, or to conduct post-marketing surveillance, as required by the Food and Drug Administration; v) to notify a person about exposure to a possible communicable disease; vi) to your employer if, we are conducting an evaluation relating to the medical surveillance of the employer's workplace or to evaluate whether you have a work related injury and only to the extent that the disclosure concerns such surveillance or injury.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, disciplinary proceedings and other administrative and judicial actions undertaken by the government by law to over the health care system.

Abuse or Neglect: If we believe that you are a victim of abuse, neglect or domestic violence, even without your agreement, we may release protected health information if the physician feels it is in the best interest of the patient and the physician has exercised his/her professional judgment to reach the decision. If we make such a disclosure, you will be notified promptly unless notification to you would place you at serious risk of harm or is otherwise not in your best interest.

For Judicial and Administrative Proceedings: We may disclose protected health information as required by a court or administrative order, or in some instances in response to a subpoena or discovery request if it is accompanied by satisfactory assurances. Law Enforcement: Policy and other law enforcement may seek medical information from us and we may release this information under limited circumstances, for example, when the request is accompanied by a warrant, subpoena, court order, or similar legal process, or when law enforcement needs specific information to locate a suspect or stop a crime.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their research as been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers' Compensation: Your protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: We may disclose your medical information as required or permitted by the Secretary of the Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act, as amended and interpreted from time to time.

2. Your Rights

Restriction of your protected health information. You have the right to request in writing to us to restrict how we use and disclose your protected health information. We do not have to agree to the restrictions that you request. If we do agree to the restrictions, we will comply with the restrictions, except in emergency circumstances. We also have the right to ask you to revoke a restriction. Please request a Restriction form for your use and contact our Privacy Officer if you have any questions.

Confidential Communications. You have the right to request in writing that we restrict the way in which we communicate information regarding your health, heath care services, or payment. For example, you may ask that we communicate with you only at your home, not at your workplace. We will use reasonable efforts to accommodate your request. Please request a Confidential Communications form for your use and contact our Privacy Officer if you have any questions.

Access to your protected health information. You have the right to inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. In some circumstances, you may have a right to have this decision reviewed. Please request a Patient Access to Medical Records form for your use and contact our Privacy Officer if you have questions.

Amending your protected health information. You have the right to request an amendment of protected health information about you in a designated record set for as long as we maintain this information. For instance, you can request that we correct an incorrect office visit date in your records. We may accept or deny this request and will inform the patient in writing of the decision within 60 days. We can deny your request in certain circumstances, such as when we believe that your information is accurate and complete. You have the right to file a statement of disagreement with us, to which we may file a rebuttal. A copy of any such rebuttal will be forwarded to you. Please request a Medical Record Amendment form for your use and contact our Privacy Officer if you have questions.

Accounting of Non-authorized Disclosures. This right applies to disclosures for purposes other than treatment, payment or healthcare operations. It excludes those disclosures made pursuant to a signed authorization, or to family members or friends involved in your care, or for notification purposes, for national security, law enforcement, or in response to an individual's request for access. You have the right to request an accounting of disclosures made by us for any timeframe not greater then six years prior to your request, but no earlier April 14, 2003. Your request will be filled at no cost to you once every 12 months. For additional accountings, you will be notified in advance of the cost and give an opportunity to continue or withdraw your request. Please request an Accounting of Non-Authorized Use or Disclosure form for your use and contact our Privacy Officer if you have any questions.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically, you may obtain a paper copy from any of our staff members.

3. Complaints.

If you believe that any of your rights with respect to your protected health information have been violated by us, our employees or agents, you may file a complaint with us by contacting our Privacy Officer at Carolina Retina Center, 7620 Trenholm Road Ext., Columbia, SC 29223 and/or with the government at Centers for Medicare & Medicaid Services at HIPAA Complaint, 7500 Security Blvd., C5-24-04, Baltimore, MD 21244. Carolina Retina Center also has a Complaint form for your use. Contact our Privacy Officer if you have any questions. Under no circumstances will we take any retaliation against you for filing a compliant.

Our Duties. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to your medical information. We must comply with the Notice currently in effect.

We reserve the right to revise this Notice and will revise the Notice if we materially change any use, disclosure, individual right or legal duty or other privacy practice stated in this Notice. If we revise a Notice, copies will be available by asking a member of our staff. We reserve the right to change our privacy practices retroactively with respect to information that we created or received prior to issuing a revised Notice.