LAFERLA FAMILY EYECARE OD PC


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Dr. Jeff D. LaFerla, OD Dr. Joni K. LaFerla, OD
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\tNOTICE OF PRIVACY PRACTICES
\tDate of Last Revision: 12-06-03\t\t\t
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\tTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
\t THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
\t
\tTHIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE OF JEFF D. LAFERLA, OD, pc, AND
\tJONI K. LAFERLA, OD, pc WHETHER MADE BY THE PRACTICE OR AN ASSOCIATED FACILITY.
\t
\tThis notice describes our Practice?s policies, which extend to:
?\tAny health care professional authorized to enter information into your chart (including physicians, assistants, etc.);
?\tAll areas of the Practice (front desk, administration, billing and collection, etc.);
?\tAll employees, staff and other personnel working for or with our Practice (janitors, computer support personnel, etc.)
?\tOur business associates (labs, referring offices, physical therapists, optical supply companies, etc.).
\t
\tThe Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the
\t Health Insurance Portability and Accountability Act of 1996 (HIPAA).
\t
\tOUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION:
\t
\tWe understand that your medical information is personal to you and are committed to protecting your information. As our patient, we create paper and
\telectronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to
\tprovide for your care and to comply with certain legal requirements. We are required by law to:
?\tmake sure that the protected health information about you is kept private;
?\tprovide you access to this Notice of Privacy Practices and your legal rights regarding your protected health information
?\tfollow the conditions of the Notice that is currently in effect.
\t
\tHOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
\t
\tThe following categories describe ways we use and disclose protected health information that we have and share with others. Each category of
\t uses or disclosures provides a general explanation and provides some examples of uses. Not every use or disclosure in a category is either listed
\tor actually in place. The explanation is provided for your general information only.
\t
?\tMedical Treatment
\tWe use your medical information to provide current or prospective medical treatment or services and may disclose your medical information
\t to doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, a doctor to whom we refer you
\t for further care may need your medical record (s), prescriptions, requests of lab work and photos and visual fields. We may discuss your
\tmedical information with you to recommend possible treatment options or alternatives that may be of interest to you. We may disclose your
\t medical information to others involved in your medical care after you leave the Practice; this may include your family members, personal
\trepresentatives authorized by you or by a legal mandate (a guardian or person named to handle your medical decisions, should you
\tbecome incompetent).
\t
?\tPayment
\tWe may disclose your medical information for services and procedures so they may be billed and collected from you, an insurance company,
\tor any other third party payor. For example, we may need to give your health care information, about treatment you received to obtain payment
\t or reimbursement for the care provided to you by us. We may also tell your health plan and/or referring physician about a treatment you
\tare going to receive to obtain prior approval or to determine whether your plan will cover the treatment, to facilitate payment of a referring
\tphysician, or the like.
\t

?\tHealth Care Operations
\tWe may use and disclose medical information about you so that we can run our Practice more efficiently and ensure our patients receive quality care. These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, deciding what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other Practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
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\tWe may use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for helping us comply with our legal requirements, to auditors to verify records, to billing companies to aid us in this process, etc. We shall endeavor, at all times when business associates are used, to advise them of their continued obligation to maintain the privacy of your medical records.
?\tAppointment and Patient Recall Reminders
\tWe may ask that you sign in writing at the Receptionists' Desk, a "Sign In" log on the day of your appointment. On the day of your appointment, we may call your name in the reception area to bring you to the treatment area. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with the Practice or that you are due to receive periodic care from the Practice. This contact may be by phone, in writing, e-mail, or otherwise and may involve the leaving of an e-mail, a message on an answering machine, or otherwise which could (potentially) be received or intercepted by others.
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?\tEmergency Situations
\tIn addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status and location.
\t
?\tResearch
\tUnder certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols and the like. All research projects are subject to an approval process, which evaluates a proposed research project and its use of medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will obtain an Authorization from you before using or disclosing your individually identifiable health information unless the authorization requirement has been waived. If possible, we will make the information non-identifiable to a specific patient. If the information has been sufficiently de-identified, an authorization for the use or disclosure is not required.
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?\tRequired By Law.
\tWe will disclose medical information about you when required to do so by federal, state or local law enforcement agencies.
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?\tTo Avert a Serious Threat to Health or Safety.
\tWe may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
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?\tWorkers' Compensation
\tWe may release your medical information for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
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?\tPublic Health Risks
\tLaw or public policy may require us to disclose medical information about you for public health activities. These activities generally include the following:
?\tto prevent or control disease, injury or disability;
?\tto report births and deaths;
?\tto report child abuse or neglect;
?\tto report reactions to medications or problems with products;
?\tto notify people of recalls of products they may be using;
?\tto notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
?\tto notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
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?\tInvestigation and Government Activities
\tWe may disclose medical information to a local, state or federal agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the payor, the government and other regulatory agencies to monitor the health care system, government programs, and compliance with civil rights laws.
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?\tLawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. This is particularly true if you make your health an issue. We may also disclose medical information about you in response to a subpoena, discovery request, or

other lawful process by someone else involved in the dispute. We shall attempt in these cases to tell you about the request so that you may
obtain an order protecting the information requested if you so desire. We may use such information to defend ourselves, or any member of
our Practice in any actual or threatened action.

?\tLaw Enforcement
\t\tWe may release medical information if asked to do so by a law enforcement official:
?\tIn response to a court order, subpoena, warrant, summons or similar process;
?\tTo identify or locate a suspect, fugitive, material witness, or missing person;
?\tAbout the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
?\tAbout a death we believe may be the result of criminal conduct;
?\tAbout criminal conduct at the Practice; and
?\tIn emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the
?\t person who committed the crime.

?\tCoroners, Medical Examiners and Funeral Directors
\tWe may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
\tperson or determine the cause of death. We may also release medical information about patients of the Practice to funeral directors as
\t necessary to carry out their duties.
\t
?\tInmates
\tIf you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information
\tabout you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you
\twith health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional
\t institution.
\t
\tCHANGES TO THIS NOTICE
\tWe reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information
\twe already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice.
\tThe notice will contain on the first page, in the top left-hand corner, the date of last revision. In addition, each time you visit the Practice for
\ttreatment or health care services you may request a copy of the current notice in effect.
\t
\tCOMPLAINTS
\tIf you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of
\tHealth and Human Services. To file a complaint with the Practice, contact our HIPAA Compliance Officer, who will direct you on how to file an
\toffice complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.
\t[The HIPAA Compliance Officer, Kelly McCurley, can be reached at this number : 816-741-6737] You will not be penalized for
\t filing a complaint.
\t
\tOTHER USES OF MEDICAL INFORMATION
\tOther 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
\t permission, unless those uses can be reasonably inferred from the intended uses covered by our policy. If you have provided us with your
\tpermission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission,
\twe will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are
\tunable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that
\twe provided to you.
\t
\t
\t
\tPATIENT RIGHTS
\t
\tTHIS SECTION DESCRIBES YOUR RIGHTS AND OUR OBLIGATIONS REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
\t
\tYou have the following rights regarding medical information we maintain about you:
?\tRight to Inspect and Copy
\tYou have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own
\tmedical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others
\t related to you or under your care (guardian or custodial) may also be disclosed.
\t
\tTo inspect and copy your medical record, you must submit your request in writing to our Compliance Officer. If you request a copy
\tof the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request.
\t
Dr. Jeff D. LaFerla, OD Dr. Joni K. LaFerla, OD
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?\tRight to Amend
\tIf you feel that the medical information we have about you in your record is incorrect or incomplete, then you may ask us to amend the information, following the procedure below. You have the right to request an amendment for as long as the Practice maintains your medical record.
\t
\tTo request an amendment, your request must be submitted in writing, along with your intended amendment and a reason that supports your request to amend. The amendment must be dated and signed by you and notarized.
\t
\tWe may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
?\tWas not created by us, unless the person or entity that created the information is no longer available to make the amendment;
?\tIs not part of the medical information kept by or for the Practice;
?\tIs not part of the information which you would be permitted to inspect and copy; or
?\tIs inaccurate and incomplete.
\t
?\tRight to an Accounting of Disclosures
\tYou have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you, to others.
\t
\tTo request this list, you must submit your request in writing. Your request must state a time period not longer than six (6) years back and may not include dates before April 14, 2003 (or the actual implementation date of the HIPAA Privacy Regulations). Your request should indicate in what form you want the list (for example, on paper, electronically). We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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?\tRight to Request Restrictions
\tYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend). For example, you could ask that we not use or disclose information about a particular treatment you received.
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\tWe are not required to agree to your request, and we may not be able to comply with your request. If we do agree, we will comply with your request. We shall not comply (even with a written request) if the information is required disclosed by law.
\t
\tTo request restrictions, you must make your request in writing. In your request, you must indicate:
?\twhat information you want to limit;
?\twhether you want to limit our use, disclosure or both; and
?\tto whom you want the limits to apply, (e.g., disclosures to your children, parents, spouse, etc.)
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?\tRight to Request Confidential Communications
\tYou have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, that we not leave voice mail or e-mail, or the like.
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\tTo request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish us to contact you.
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?\tRight to a Paper Copy of This Notice
\tYou have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
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Dr. Jeff D. LaFerla, OD Dr. Joni K. LaFerla, OD
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?\tCoroners, Medical Examiners and Funeral Directors
\tWe may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
\tperson or determine the cause of death. We may also release medical information about patients of the Practice to funeral directors as
\t necessary to carry out their duties.
\t
?\tInmates
\tIf you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information
\tabout you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you
\twith health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional
\t institution.
\t
\tCHANGES TO THIS NOTICE
\tWe reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information
\twe already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice.
\tThe notice will contain on the first page, in the top left-hand corner, the date of last revision. In addition, each time you visit the Practice for
\ttreatment or health care services you may request a copy of the current notice in effect.
\t
\tCOMPLAINTS
\tIf you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of
\tHealth and Human Services. To file a complaint with the Practice, contact our HIPAA Compliance Officer, who will direct you on how to file an
\toffice complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.
\t[The HIPAA Compliance Officer, Kelly McCurley, can be reached at this number : 816-741-6737] You will not be penalized for
\t filing a complaint.
\t
\tOTHER USES OF MEDICAL INFORMATION
\tOther 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
\t permission, unless those uses can be reasonably inferred from the intended uses covered by our policy. If you have provided us with your
\tpermission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission,
\twe will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are
\tunable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that
\twe provided to you.
\t
\t
\t
\tPATIENT RIGHTS
\t
\tTHIS SECTION DESCRIBES YOUR RIGHTS AND OUR OBLIGATIONS REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
\t
\tYou have the following rights regarding medical information we maintain about you:
?\tRight to Inspect and Copy
\tYou have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own
\tmedical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others
\t related to you or under your care (guardian or custodial) may also be disclosed.
\t
\tTo inspect and copy your medical record, you must submit your request in writing to our Compliance Officer. If you request a copy
\tof the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request.
\t
\t
\t
\t
\tWe may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information,
\tyou may request that our Compliance Committee review the denial. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome and recommendations from that review.

Dr. Jeff D. LaFerla, OD Dr. Joni K. LaFerla, OD
\t\t\t

?\tCoroners, Medical Examiners and Funeral Directors
\tWe may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
\tperson or determine the cause of death. We may also release medical information about patients of the Practice to funeral directors as
\t necessary to carry out their duties.
\t
?\tInmates
\tIf you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information
\tabout you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you
\twith health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional
\t institution.
\t
\tCHANGES TO THIS NOTICE
\tWe reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information
\twe already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice.
\tThe notice will contain on the first page, in the top left-hand corner, the date of last revision. In addition, each time you visit the Practice for
\ttreatment or health care services you may request a copy of the current notice in effect.
\t
\tCOMPLAINTS
\tIf you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of
\tHealth and Human Services. To file a complaint with the Practice, contact our HIPAA Compliance Officer, who will direct you on how to file an
\toffice complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.
\t[The HIPAA Compliance Officer, Kelly McCurley, can be reached at this number : 816-741-6737] You will not be penalized for
\t filing a complaint.
\t
\tOTHER USES OF MEDICAL INFORMATION
\tOther 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
\t permission, unless those uses can be reasonably inferred from the intended uses covered by our policy. If you have provided us with your
\tpermission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission,
\twe will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are
\tunable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that
\twe provided to you.
\t
\t
\t
\tPATIENT RIGHTS
\t
\tTHIS SECTION DESCRIBES YOUR RIGHTS AND OUR OBLIGATIONS REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
\t
\tYou have the following rights regarding medical information we maintain about you:
?\tRight to Inspect and Copy
\tYou have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own
\tmedical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others
\t related to you or under your care (guardian or custodial) may also be disclosed.
\t
\tTo inspect and copy your medical record, you must submit your request in writing to our Compliance Officer. If you request a copy
\tof the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request.
\t
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information,
\tyou may request that our Compliance Committee review the denial. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome and recommendations from that review.

Dr. Jeff D. LaFerla, OD Dr. Joni K. LaFerla, OD
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