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 read it carefully. If you have any questions about this Notice, please write or call our Privacy Contact, Debbie, at 801-312-2010 at our Salt Lake Office.
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 (address, telephone number, etc.), 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 are required to abide by the terms of this Notice of Privacy Practices. We reserve the
right to make changes to the terms of our notice at any time. This notice will be effective beginning April 14, 2003, for all protected health information that we maintain at the time of writing and includes all future records as applicable.
Uses and Disclosures of Protected Health Information
You will be asked by Retina Associates of Utah, P.C., to sign an acknowledgment form that
you have received a copy of this Notice of Privacy Practices. Once you have consented the use and disclosure of your protected health information carry out treatment, payment, or health care
operations, your Retina Associates of Utah physician (“your physician”), his/her staff and associates will use or disclose your protected health information as described in this Notice. The physician’s associates include those who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to assist in getting reimbursement for your health care charges and to support the operation of our practice.
Following are explanations of the types of uses and disclosures of your protected health
Information that Retina Associates of Utah, P.C. is permitted to make once you have signed the
acknowledgement form. These are meant to be examples and are not all-inclusive.
Treatment. We will use and disclose your protected health information to provide,
Coordinate, or manage your health care and related services. This includes coordination or
management of your health care with a third party that has already obtained your permission to have access to your protected health information or one who would diagnose or treat you further. For example, the doctor who referred you to us, the hospital where you would have surgery, or a home health or nursing care agency that provides care to you. In addition, we may disclose your protected health information to another doctor or health care provider (e.g., radiologist, specialist who performs testing, laboratory, pharmacy, etc.), who, at the request of your physician, becomes
involved in your care by providing a related diagnosis or treatment to your physician. Though we will take every precaution to safeguard your protected health information, we cannot be held accountable for accidental disclosures that are overheard verbally or seen in writing.
For example, our walls and doors are not soundproof and many of our patients are hard of hearing, therefore, information may be overheard in the next room, in the hallway, in a diagnostic testing room, or written information that could be glanced at in passing.
Payment. Your protected health information will be used, as needed, to obtain payment for
your healthcare services. This may include certain activities that your health insurance plan may
undertake before it approves or pays for the healthcare services we recommend for you such as:
making a determination of eligibility or coverage for insurance benefits, reviewing services
provided you for medical necessity, and undertaking utilization review activities.
Healthcare Operations. We may use or disclose your protected information to support the
business activities of our practice within the scope of current privacy laws for protected health
information. For example, we may disclose your protected health information to a medical student
who would follow your physician as part of his/her studies. At the front reception desk, we will ask
your name and verbally verify the accuracy of insurance, demographics (address, phone, etc.), or
other information handwritten by you. We may use or disclose your protected health information,
within limitations, to contact you to set up or remind your of an appointment as requested by your
physician or another health care provider outside of our practice.
We will share your protected health information with our third party “business associates”
that are hired or utilized to perform various activities for the practice (for example, billing services,
transcription services, computer hardware and software technologists, electronic health record
monitors). Whenever an arrangement between our practice and a business associate involves the
use or disclosure of your protected health information, we will have each business associate agree in writing to protect the privacy of your protected health information according to our arrangement. Any restriction you wish to request with your physician. You may request a restriction on the form, “Patient Request to Restrict Use or Disclosure of Protected Health Information,” and discuss it by phone or in person with our Privacy Contact or with one or our front office personnel to ensure it is noted and filed.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
You have the right to have your physician amend your protected health information. This means you may request in writing an amendment of protected health information about you in a designated record set for as long as we maintain this information. We will comply with your
request in the event we find the information is false, inaccurate, or misleading. In certain cases, we may deny your request for an amendment. Please contact our Privacy Contact to determine if you have questions about amending your medical record.
You have the right to receive an account of certain disclosures we have made, if any, of
your protected health information. This right applies to disclosures for purposes other than
treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It
excludes disclosures we may have made directly to you, for a facility directory, to family members
or friends involved in your care, or for notification purposes. You have the right to receive specific
information regarding the disclosures that occurred since April 14, 2003. The accounting of
disclosures will be at no cost to you.
You may complain to our Privacy Contact or to the Secretary of Health and Human Services
if you believe your privacy rights have been violated by our practice
Identity Theft Prevention and Detection and Red Flags Rule Compliance
It is the policy of Retina Associates of Utah, P.C. and its physicians to follow all federal and
state laws and reporting requirements regarding identity theft. Specifically, this policy outlines how Retina Associates of Utah, P.C. and its physicians will (1) identify, (2) detect and (3) respond to “red flags.” A “red flag” includes a pattern, practice, or specific account or record activity that
indicates possible identity theft. This policy is effective January 1, 2010 and continues until further notice.
Identify Red Flags. In the course of caring for patients, we may encounter inconsistent or suspicious documents, information, or activity that may signal identify theft, including a billing statement, medical record or treatment, or complaint or question from a health care provider or health insurer.
Detect Red Flags. The staff of Retina Associates of Utah, P.C. will alert for discrepancies in documents and patient information that suggest risk of identity theft or fraud. We will verify patient identity, address and insurance coverage at the time of patient check-in. We will also ask for a copy of a valid and current drivers license or other photo identification at the time of check-in. This requirement will be waived for patients who have visited the practice within the last six months, once we have a valid photo identification in the patient’s electronic and paper chart.
Respond to Red Flags. If an employee of Retina Associates of Utah detects fraudulent activity or if a patient claims to be a victim of identify theft, we will respond to and investigate the situation. If following investigation, it appears that the patient has been a victim of identify theft, Retina Associates of Utah, P.C., will promptly consider what further remedial act/notifications may be needed under the circumstances. The staff of Retina Associates of Utah, P.C. will determine whether any other records and/or ancillary service providers are linked to inaccurate information. Any additional files containing information relevant to identify theft will be removed and appropriate action taken. The patient is responsible for contacting ancillary service providers. Iffollowing investigation, it does not appear that the patient has been a victim of identify theft, Retina Associates of Utah, P.C., will take whatever action it deems appropriate.
Our Privacy Contact is Debbie Wilkinson, who can be contacted at (801) 312-2010 or
firstname.lastname@example.org for further information about the complaint process or this Notice of Privacy Practices. You may also send your inquiries to her at our Salt Lake Office at 5169 South
Cottonwood Street, Suite 630, Salt Lake City, Utah 84107. We reserve the right to change our Privacy practices and to alter this Notice according to those changes. Upon your request, we will provide you with any revisions of the Notice of Privacy Practices, in the event that our Notice changes, by calling the office and requesting a revised copy to be sent to you in the mail or by asking for one at the time of your appointment. This revised Notice, which became effective April 14, 2003, is reviewed annually and remains in place with continual adjustments made as appropriate.