The John-Kenyon Eye Center

HIPAA Privacy Notice
April 1, 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 or concerns about this notice please contact Erin Bowman, Privacy Officer, 1305 Wall Street, Jeffersonville, IN 47130, 812-288-9011,ebowman@johnkenyon.com

We at the John-Kenyon Eye Center (John Eye Clinic) and the John-Kenyon Center for Eye Surgery (Surgicare) are committed to protecting your personal health information. This “Protected Health Information” consists of your past, present or future physical or mental health or condition; the provision of your health care, and the past, present or future payment for the provision of your health care. The use and disclosure of your Protected Health Information will be to carry out treatment, payment, and health care operations of the John-Kenyon Eye Center, Surgicare and participating anesthesiologists.

Private Medical Information may be used and disclosed in the following circumstances:

• For Treatment: When medically necessary, your information may be shared among doctors, technicians and other employees of the John-Kenyon Eye Center or the Surgery Center and with other healthcare providers actively involved in your care. For example, we may use and disclose your medical information when referring you to another specialist who may more adequately handle your condition.
• For Payment: We may use and disclose information that is necessary in order to file insurance claims and successfully complete all billing and collection procedures. For example, we may inform your health care plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
• For Health Care Operations: We may use and disclose your Protected Health Information in the course of operating our clinic and surgical center. These uses are necessary to run our daily activities and make sure that all of our patients receive quality care. For example, we may use your medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
• Appointment Reminders and other Health-related services: We may use and disclose medical information to contact you in regard to an appointment, possible treatment options or other benefits or services that may be of interest to you. We may call you in regard to your appointment and, if necessary, leave messages on your answering machine. We may send you a notice if you missed your scheduled appointment asking you to contact us to reschedule. Another example may be contacting you about location changes, expansions and advancements we have made at the John-Kenyon Eye Center.
• Individuals Involved in Your Care or Payment for Your Care: We may release medical information to a friend or family member who is involved in or helps pay for your medical care. For example, if a family member is financially responsible for a patient and makes an inquiry about the patient’s bill.
• Research: In certain circumstances we may use and disclose your Protected Health Information to assist in research. For example, we may use information about our cataract patients as a learning aide or to project future outcomes.
• As Required By Law: We will disclose your medical information when required to do so by federal, state or local law. For example, when it is in response to a court order, subpoena, warrant, summons or similar process. Also, we may release information if the Indiana Blind Registry requires us to inform them if a patient’s vision meets certain requirements so they can provide individual services to the patient.
• To Avert Threat to Health or Safety: We may use and disclose your medical information to authorities in order to avoid a serious threat to your health and safety or the health and safety of another person. For example, we may disclose Protected Health Information to certain authorities if they request information about your driving abilities.
• For Specific Government Functions: We may use and disclose Protected Health Information when required for any specialized government or military functions including active personnel, reservist, veterans, and discharged members of the service. Also, for any person confined to a correctional institution or under any law enforcement supervision.
• Health Oversight Activities: We may use and disclose your Protected Health Information when authorized by law for oversight activities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with Medicare guidelines and civil rights. Examples may include audits, investigations, inspections, and licensure.
• Workers’ Compensation: We may release your medical information to workers’ compensation to provide benefits for work- related injuries. For example, if you are injured on the job and require our medical attention, we will release your Protected Health Information to your employer so that we may receive proper payment.
• Publicly funded services: Release of your information may be necessary to determine eligibility for publicly funded services. For example, we may disclose information when applying for assistance from the Indiana Vocational Rehabilitation, Kentucky Department for the Blind, The Knights Templar Eye Foundation and other publicly funded services that may benefit you as the patient.

Your rights regarding your Protected Health Information:

• Right to Request Restrictions: You have the right to request a restriction or limitation on how much of your Protected Health Information is disclosed. We will consider your request, but are not required to agree to it.
• Right to Inspect and Copy: You have the right to inspect your records or receive a copy of your records at any time by signing a written release. However, under certain rare circumstances we have the right to deny your request. If needed, interpretation of the records will be provided. We are required to respond to your request within 30-60 days.
• Right To Amend: You have the right to ask us to amend your medical records if you feel as though we have made an error in your record. Your request must be in writing. We may deny your request. Some examples of why we may deny your request are: if it is not in writing, if it does not include a reason for the request, if the medical information is correct and accurate, if the medical information was not created by us, or if we’re not permitted to disclose the information.
• Right to Accounting of Disclosures: You have the right to get a list of when, to whom, for what purpose, and what content of your Protected Health Information has been released. The list will not include any disclosures to law enforcement, for national security purposes, or before April 2003. Once we have received your request, we will respond to it within 60 days. Your request should specify a time period and indicate in what form you want the list such as on paper or electronically. Your request can include disclosures going back as far as 6 years. You’re entitled to one free list a year. There may be a charge for any additional lists requested within that year.
• Right to request confidential communications: You have the right to choose how we contact you. Your request may specify how or where you wish to be contacted. We will not ask you the reason for the request. For example, you can ask that we only contact you at work or by mail. We must agree to your request as long as it is reasonably easy for us to do so.
• Right to a copy of this notice: You have a right to receive a copy of this notice either on paper or electronically. You may obtain an additional or updated copy by contacting our Compliance Officer or going to our website at www.johnkenyon.com

CHANGES TO THIS NOTICE:

• We reserve the right to change this notice. An updated copy is available upon request. We will post a copy of this notice at all locations of the John-Kenyon Eye Center with the effective date of the change. An updated copy will be available to you upon request.

COMPLAINTS:

• If you think we have violated your privacy rights or disagree with the way we used your Protected Health Information then you may file a complaint with the Privacy Officer, Erin Bowman (contact information listed on first page of notice). You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201 or by email at HHS.Mail@hhs.gov. There will be no retaliation if you make such complaints.

OTHER USES OF MEDICAL INFORMATION:

• Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose your Protected Health Information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your Protected Health Information for the reasons covered by your written authorization. You understand that we are unable to take back and disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.