Eye Surgeons Associates, P.C.

THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU MAY ACCESS THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our “Notice of Privacy Practices” (hereinafter referred to as Notice) outlines our legal duties and practices with respect to maintaining the privacy of protected health information. We are dedicated to maintaining the privacy of all protected health information and will abide by the terms of the Notice currently in effect.

Provision of Notice: Beginning on the effective date, we will provide the Notice to every patient with whom we have a direct treatment relationship no later than the date of the first treatment. The Notice is available at all our offices for anyone who wants to evaluate our privacy practices when making a decision regarding whether to seek treatment from Eye Surgeons Associates. The Notice is also available on our website at www.eyesurgeonspc.com .

Documentation of Provision of Notice: When a patient receives the Notice, we ask the patient to sign its “Receipt of Notice of Privacy Practices” form, which is filed with the patient’s medical record. If the patient refuses to sign the form, it is noted in the medical record that the patient was given a Notice and refused to sign the form.

Effective Date and Changes to Notice: This Notice is effective April 14, 2003. We reserve the right to revise this Notice whenever there is a material change to our legal duties and practices stated in the Notice. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is stated. A revised Notice will be available on the effective date of revision at all our offices for anyone who has received a previous Notice.

Complaints: If you believe we have violated your legal rights or our privacy practices, we encourage you to file a complaint with our Privacy Officer. Complaints should be filed in writing within 180 days of the time you became aware of the acts or omissions that are the subject of the complaint. The practice investigates each complaint and will provide a written reply to the person who filed the complaint within 30 days of our receipt of the written complaint.

You may also file a complaint with the Secretary of the Department of Health and Human Services. Such complaints must be in writing, must name our practice, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Washington, DC 20201.

We respect the right to file a complaint and will not take any adverse action, nor allow any employee to take any adverse action against any person who files a complaint.

Privacy Officer: We have designated someone to act as our Privacy Officer and serve as a contact person for all issues related to our privacy practices. If you have any questions about this Notice or our privacy practices, you may call any of our offices and ask for the Privacy Officer or mail your inquiry to Privacy Officer, Eye Surgeons Associates, 2001 5th Street, Suite 49, Silvis, IL 61282.

USES AND DISCLOSURES
OF PROTECTED HEALTH INFORMATION

We take all reasonable steps to ensure that protected health information we request, use, and disclose is the minimum amount of such information needed to achieve the purpose for which it is intended.

We take all reasonable steps to ensure that protected health information is only used by and disclosed to individuals that have a right to such information. Toward that end, we make reasonable efforts to verify the identity of those using or receiving protected health information.

Uses and Disclosures – Treatment, Payment, and Health Care Operations

We use and disclose protected health information for payment, treatment, and health care operations. Treatment includes those activities related to providing services to the patient, including releasing information to other health care providers involved in the patient’s care. Payment relates to all activities associated with getting reimbursed for services provided, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. Health care operations includes a number of areas, including quality assurance and peer review activities.

Uses and Disclosures – Not Requiring Authorization

Those Involved in Individual’s Care: We disclose protected health information to those involved in a patient’s care when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in our professional judgment.

When the patient is not present, we determine if law authorizes the disclosure of the patient’s protected health information, and if so, we disclose only the information directly relevant to the purpose for which it is intended.

We do not disclose protected health information to a suspected abuser, if, in our professional judgment, there is reason to believe that such disclosure could cause the patient serious harm.

Required by Law: We disclose protected health information to public health officials. This includes reporting of communicable diseases and other conditions, sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated reports of injury, medical conditions or procedures, or food-borne illness including but not limited to adverse reactions to immunizations, cancer, adverse pregnancy outcomes, death, birth.

We also disclose protected health information regarding victims of abuse, neglect, or domestic violence. We may disclose information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse.

When reporting disclosures required by law, we report such disclosures to patients and their agents or personal representatives unless, in the exercise of our professional judgment, we believe that informing such individuals would place someone at risk of serious harm. We will also not inform a person who we believe is responsible for abuse, neglect, or other injury, if we believe that informing such a person would not be in the best interests of the individual, as determined by our professional judgment.

Health Oversight Activities: We use and disclose protected health information as required by law for health oversight activities. Such information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but limited to hospital peer review, managed care peer review, or Medicaid or Medicare peer review.

Judicial and Administrative Proceedings: We disclose protected health information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal.

Law Enforcement Purposes: We disclose protected health information to law enforcement officials for law enforcement purposes.

Organ, Eye, Cadaveric or Tissue Donations: We use and disclose protected health information to facilitate organ, eye or tissue donations.

To Avert a Serious Threat to Health or Safety: We use and disclose protected health information to public health and other authorities as required by law to avert a serious threat to health or safety.

Specialized Government Functions: We use and disclose protected health information for military and veteran activities, national security and intelligence activities, and other similar activities as required by law.

Emergency Situations: We use and disclose protected health information as appropriate to provide treatment in emergency situations. In those instances where we have not previously provided our Notice of Privacy Practices to a patient who receives direct treatment in an emergency situation, we will provide the Notice to the patient or personal representative as soon as practicable following the provision of the emergency treatment.

Marketing Purposes: We do not use or disclose any protected health information for marketing purposes. The practice does engage in communications about products and services that encourages recipients of the communication to purchase or use the product or service for treatment, to direct or recommend alternative treatments, therapies, health care providers, or settings of care to the individual. These activities are not considered marketing.

Research: We do engage in research to improve patient care. If such activities require the use or disclose of protected health information, a signed release will be obtained from the patient prior to the patient being included in the research activity or study.

Appointment Reminders: We will contact patients or their personal representatives with appointment reminders or information about treatment alternatives or other heath- related benefits and services that may be of benefit to the patient.

Other Uses and Disclosures: We do not disclose protected health information to an employer or health plan sponsor, for underwriting and related purposes, for facility directories, to brokers and agents, or for fundraising. If an individual wants the practice to release his or her protected health information to employers or health plan sponsors, for underwriting and related purposes, for facility directories, or to brokers and agents, then he or she can contact the practice and complete an appropriate written authorization.

INDIVIDUAL RIGHTS

Individual Rights – Accounting for Disclosures of Protected Health Information

We track all disclosures of a patient’s protected health information that occur for other than the purposes of treatment, payment, and health care operations, that are not made to the individual or to a person involved in the patient’s care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials.

We allow an individual to request one report of disclosures we track within a 12-month period free of charge. The practice charges a reasonable fee for more frequent requests. The charge will be: $20 handling fee plus 75 cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for pages 51 to end. These fees are in accordance within the allowable fees in the states of Iowa and Illinois. An individual can request a report of tracked disclosures for a period of up to six years prior to the date of the request. Requests for shorter periods will be accepted. However, patients may only request an report of tracked disclosures made on or after the effective date of this Notice.

We respond to all requests for a report of tracked disclosures within 60 days of receipt of the request. If the practice cannot do so within 60 days, the practice informs the requestor of such and provides a reason for the delay and the expected date of completion. Only one 30-day extension is permitted.

A request for a report of tracked disclosures must be made in writing and mailed or sent to the Privacy Officer listed above.

Individual Rights – Inspect and Copy Protected Health Information

We allow individuals to inspect and copy their protected health information, document all requests, respond to those requests in a timely fashion, inform individuals of their appeal rights when a request is rejected in whole or in part, and charge a reasonable fee for the copying of records.

We review requests in a timely fashion and act on requests for access generally within 30 days. We may have a single extension of 30 days, if needed to act on a request. Each request will be accepted or denied and the requestor notified in writing. If a request is denied, the requestor is informed if the denial is “reviewable” or not. The requestor has the right to have any denial reviewed by a licensed health care professional who is designated by Eye Surgeons Associates as a reviewing official and who did not participate in the original decision to deny. We inform the requestor of the decision of the reviewing official and adhere to the decision.

We charge reasonable fees based on actual cost of fulfilling the request. We will determine the appropriate charge for providing the requested records and inform the requestor in advance of providing the records. If the requestor agrees to pay the fee in advance, the records will be provided. Otherwise, the records will not be provided, unless the Privacy Officer determines that the charge is burdensome to the requestor.

Fees for copying of records will be as follows: $20 handling fee plus 75 cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for pages 51 to end; plus actual expenses related to the copying of x-rays, CAT scans, and similar. We limit charges for records to the amounts allowed under Illinois and Iowa law.

Requests for the inspection and copying of records must be sent in writing to the Privacy Officer listed above.

Individual Rights – Request Amendment to Protected Health Information

We allow individuals to request an amendment to their protected health information in the patient’s medical record or the patient’s billing record. We document all requests, respond to those requests in a timely fashion, and inform individuals of their appeal rights when a request is denied in whole or in part.

Generally, we will act on a request for amendment no later than 60 days after receipt of such a request. If we cannot act on the amendment within 60 days, we will extend the time for such action by 30 days and, within the 60-day time limit, provides the requestor with a written statement of the reasons for the delay and the date by which we will complete action on the request. Only one such extension is allowed.

If we deny the request, in whole or in part, we provide the requestor with a written denial in a timely fashion. We allow a requestor to submit a written statement disagreeing with the denial of all or part of the initial request. The statement must include the basis of the disagreement. We limit the length of a statement of disagreement to one page.

Requests to amend protected health information must be sent in writing to the Privacy Officer listed above.

Individual Rights – Request Confidential Communications

We accommodate all reasonable requests to keep communications confidential. We determine the reasonableness based on the administrative difficulty of complying with the request.

A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the Privacy Officer listed above. No reason for the request needs to be stated.

We will reject a request for confidential communications if no independently verifiable method of communication, such as a mailing address or published telephone number, is provided for communications or if the requestor has not provided information as to how payment will be handled. We will not reject a request for confidential information if the requestor indicates that the communication will cause endangerment.

Individual Rights – Request Restriction of Disclosures

We accept all requests for restrictions of disclosures of protected health information. The practice does not agree to any restrictions in the use or disclosure of protected health information other than those listed in this or subsequent Notices.

All requests for restrictions of disclosures must be submitted in writing. They must be sent to the attention of the Privacy Officer listed above. The Privacy Officer will notify the requestor in writing that the practice does not accept restrictions of disclosure.

Individual Rights – Authorizations

We obtain a written authorization from a patient or the patient’s representative for the use or disclosure of protected health information for other than treatment, payment, or health care operations.

We do not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for purpose of creating protected health information for disclosure to a third party (e.g., pre-employment or life insurance physicals).

In Illinois and Iowa, a specific written authorization is required to disclose or release mental health treatment, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information.

We allow an individual to revoke an authorization at any time. The revocation must be in writing and must be sent to the attention of the Privacy Officer listed above. However, in any case we will be able to use or disclose the protected health information to the extent we have taken action in reliance on the authorization.

Individual Rights – Waiver of Rights

We never require an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law.