NOTICE OF PRIVACY PRACTICES
Community Eye Center PA
St. Lucy’s Outpatient Surgery Center, Inc.
Community Eye Optical, LC
Gulf Coast Anesthesia
21275 Olean Blvd. Port Charlotte, Florida 33952
Date of Last Revision 05-08-03 Effective: April 14, 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.THIS NOTICE
APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE
BY THE PRACTICE OR AN ASSOCIATED FACILITY.
The Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health
and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996
(HIPAA). Community Eye Center, St. Lucy’s Surgery Center, Community Eye Optical, and Gulf Coast
Anesthesia, together operate as an Organized Healthcare Arrangement for the purpose of complying with the
privacy standards. This notice describes our Practice’s policies, which extend to any health care professional
authorized to enter information into your chart (including physicians, RNs, COMTs, COTs, COAs, OAs). All
areas of the Practice (front desk, administration, billing and collection, etc.) all employees, staff and other
personnel that work for or with our Practice. Our Business Associates (including a billing service, or facilities
to which we refer patients), on-call physicians, and so on.
OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION
We understand that your medical information is personal to you, and we are committed to protecting the
information about you. As our patient, we create paper and electronic 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 provide
for your care and to comply with certain legal requirements. We are required by law to make sure that the
protected health information about you is kept private, provide you with a Notice of our Privacy Practices and
your legal rights with respect to protected health information about you, at your request and follow the
conditions of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe
different ways that we use and disclose protected health information that we have and share with others.
Each category of uses of disclosures provides a general explanation and provides some examples of uses.
Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for
your general information only Medical Treatment. We use previously given medical information about you to
provide you medical treatment. Therefore we may, and most likely will, disclose medical information about you
to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of
you. For example, a doctor to whom we refer you to for ongoing or further care may need your medical
record. Different areas of the Practice also may share medical information about you including your record(s),
prescriptions, requests of lab work and x-rays. We may disclose your medical information about you to people
outside the Practice who may be involved in your medical care after you leave the Practice. This may include
your family members, or other personal representatives authorized by you or by a legal mandate (a guardian
or other person who has been named to handle your medical decisions, should you become incompetent)
Payment. We may use and disclose medical information about you for services and procedures so they may
be billed and collected from you, an insurance company, or any other third party. We may tell your health
plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to
determine whether your plan will cover the treatment, to facilitate payment of a referring physician, or the like
Health Care Operations. We may use and disclose medical information about you so that we can run our
Practice more efficiently and make sure that all of 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. We may also use or disclose information about you for internal or external utilization
review and/or quality assurance, to Business Associates for purposes of helping us to comply with our legal
requirements, to auditors to verify our records, to billing companies to aid us in this process and the like. 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. Appointment and Patient Recall Reminders. We may ask that
you sign in writing at the Receptionists Desk, a Sign-In Sheet. We may contact you as a reminder that you
have an appointment. This contact may be by phone, in writing (appointment reminder card), or otherwise
and may involve the leaving a message on an answering machine, which could (potentially) be received or
intercepted by others. Emergency Situations. In 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.
Research.
Under certain circumstances, we may use and disclose medical information about you for research purposes.
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.
Required By Law.
We will disclose medical information about you when required to do so by federal, state or local law. To Avert
a Serious Threat to Health or Safety. We 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.
Organ and Tissue Donation.
If you are an organ donor, we may disclose your medical information to an organ donation and procurement
organization. Workers Compensation. We may release medical information about you for workers
compensation or similar programs.
Public Health Risks.
Law or public policy may require us to disclose medical information about you for public health activities.
These activities generally include the following: To prevent or control disease, injury or disability. To report
child abuse or neglect. To report reactions to medications or problems with products, to notify people of
recalls of products they may be using, to notify a person who may have been exposed to a disease or may be
at risk for contracting or spreading a disease or condition, or to 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.
Investigation and Government Activities.
We may disclose medical information to a local state or federal agency for activities, authorized by law. These
oversight activities include, for example, audits, investigation, inspections, and licensure.
Lawsuits 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, discovery request, subpoena or other lawful process by someone else involved
in the dispute. We may also use such information to defend ourselves, or any member of our Practice in any
actual or threatened action.
Law Enforcement.
We may release medical information if asked to do so by a law enforcement official in response to a court
order, subpoena, warrant, summons or similar process. To identify or locate a suspect, fugitive, material
witness, or missing person. About a victim of a crime if, under certain limited circumstances, we are unable to
obtain the person’s agreement. About a death we believe may be the result of criminal conduct. About
criminal conduct at the Practice. In emergency circumstances to report a crime, the location of the crime or
victims, or the identity, description or location of the person who committed the crime. Coroners, Medical
Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner.
Inmates.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or law enforcement official.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a compliant with the Practice or with the
Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our
Compliance Personnel, who will direct you on how to file an office complaint. All complaints must be submitted
in writing, and all complaints shall be investigated, without repercussion to you. You will not be penalized for
filing a complaint.
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, unless those uses can be reasonably inferred from the intended
uses above. If you have provided us with your permission to use or disclose medical information about you,
you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or
disclose medical information about you for the reasons covered by your written authorization. You understand
that we are unable 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 we provided to you.
PATIENT RIGHTS. THIS GIVES A GENERAL DESCRIPTION OF YOUR RIGHTS AND THE OBLIGATIONS OF
THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
You have the following rights regarding medical information we maintain about you Right to Inspect and Copy.
You have the right to inspect and copy medical information that may be used to make decisions about your
care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon
proof of an appropriate legal relationship, records of others related to you or under your care (guardian or
custodial) may also be disclosed. To inspect and copy your medical record, you must submit your request in
writing to our office. If you request a copy of the information, we may charge a fee for the costs of copying,
mailing or other supplies (tapes, disks, etc.) associated with your request. Right to Amend. If 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.
To 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. We 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: Was not
created by us, unless the person or entity that created the information is no longer available to make the
amendment; Is not part of the medical information kept by or for the Practice; Is not part of the information
which you would be permitted to inspect and copy; Is inaccurate and incomplete.
Right to an Accounting of Disclosures.
You 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. To 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. 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.
Right to Request Restrictions. You 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.
We 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 except that we shall not comply, even with a written request, if the
information is expected from the consent requirement or we are otherwise required to disclose the information
by law.
To request restrictions, you must make your request in writing. In your request, you must indicate: What
information you want to limit; Whether you want to limit our use, disclosure or both; To whom you want the
limits to apply (e.g., disclosure to your children, parents, spouse, etc.).
Right to Request Confidential Communications. You 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 the like. To 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.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice. You may ask to give you a copy of this notice at any time.
For any questions or concerns regarding this Notice of Privacy Practices you may contact our Compliance
Assistant, Jennifer Bones at 941-625-1325 Ext. 152.
Community Eye Center PA
St. Lucy’s Outpatient Surgery Center, Inc.
Community Eye Optical, LC
Gulf Coast Anesthesia
21275 Olean Blvd. Port Charlotte, Florida 33952
Date of Last Revision 05-08-03 Effective: April 14, 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.THIS NOTICE
APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE
BY THE PRACTICE OR AN ASSOCIATED FACILITY.
The Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health
and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996
(HIPAA). Community Eye Center, St. Lucy’s Surgery Center, Community Eye Optical, and Gulf Coast
Anesthesia, together operate as an Organized Healthcare Arrangement for the purpose of complying with the
privacy standards. This notice describes our Practice’s policies, which extend to any health care professional
authorized to enter information into your chart (including physicians, RNs, COMTs, COTs, COAs, OAs). All
areas of the Practice (front desk, administration, billing and collection, etc.) all employees, staff and other
personnel that work for or with our Practice. Our Business Associates (including a billing service, or facilities
to which we refer patients), on-call physicians, and so on.
OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION
We understand that your medical information is personal to you, and we are committed to protecting the
information about you. As our patient, we create paper and electronic 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 provide
for your care and to comply with certain legal requirements. We are required by law to make sure that the
protected health information about you is kept private, provide you with a Notice of our Privacy Practices and
your legal rights with respect to protected health information about you, at your request and follow the
conditions of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe
different ways that we use and disclose protected health information that we have and share with others.
Each category of uses of disclosures provides a general explanation and provides some examples of uses.
Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for
your general information only Medical Treatment. We use previously given medical information about you to
provide you medical treatment. Therefore we may, and most likely will, disclose medical information about you
to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of
you. For example, a doctor to whom we refer you to for ongoing or further care may need your medical
record. Different areas of the Practice also may share medical information about you including your record(s),
prescriptions, requests of lab work and x-rays. We may disclose your medical information about you to people
outside the Practice who may be involved in your medical care after you leave the Practice. This may include
your family members, or other personal representatives authorized by you or by a legal mandate (a guardian
or other person who has been named to handle your medical decisions, should you become incompetent)
Payment. We may use and disclose medical information about you for services and procedures so they may
be billed and collected from you, an insurance company, or any other third party. We may tell your health
plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to
determine whether your plan will cover the treatment, to facilitate payment of a referring physician, or the like
Health Care Operations. We may use and disclose medical information about you so that we can run our
Practice more efficiently and make sure that all of 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. We may also use or disclose information about you for internal or external utilization
review and/or quality assurance, to Business Associates for purposes of helping us to comply with our legal
requirements, to auditors to verify our records, to billing companies to aid us in this process and the like. 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. Appointment and Patient Recall Reminders. We may ask that
you sign in writing at the Receptionists Desk, a Sign-In Sheet. We may contact you as a reminder that you
have an appointment. This contact may be by phone, in writing (appointment reminder card), or otherwise
and may involve the leaving a message on an answering machine, which could (potentially) be received or
intercepted by others. Emergency Situations. In 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.
Research.
Under certain circumstances, we may use and disclose medical information about you for research purposes.
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.
Required By Law.
We will disclose medical information about you when required to do so by federal, state or local law. To Avert
a Serious Threat to Health or Safety. We 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.
Organ and Tissue Donation.
If you are an organ donor, we may disclose your medical information to an organ donation and procurement
organization. Workers Compensation. We may release medical information about you for workers
compensation or similar programs.
Public Health Risks.
Law or public policy may require us to disclose medical information about you for public health activities.
These activities generally include the following: To prevent or control disease, injury or disability. To report
child abuse or neglect. To report reactions to medications or problems with products, to notify people of
recalls of products they may be using, to notify a person who may have been exposed to a disease or may be
at risk for contracting or spreading a disease or condition, or to 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.
Investigation and Government Activities.
We may disclose medical information to a local state or federal agency for activities, authorized by law. These
oversight activities include, for example, audits, investigation, inspections, and licensure.
Lawsuits 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, discovery request, subpoena or other lawful process by someone else involved
in the dispute. We may also use such information to defend ourselves, or any member of our Practice in any
actual or threatened action.
Law Enforcement.
We may release medical information if asked to do so by a law enforcement official in response to a court
order, subpoena, warrant, summons or similar process. To identify or locate a suspect, fugitive, material
witness, or missing person. About a victim of a crime if, under certain limited circumstances, we are unable to
obtain the person’s agreement. About a death we believe may be the result of criminal conduct. About
criminal conduct at the Practice. In emergency circumstances to report a crime, the location of the crime or
victims, or the identity, description or location of the person who committed the crime. Coroners, Medical
Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner.
Inmates.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or law enforcement official.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a compliant with the Practice or with the
Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our
Compliance Personnel, who will direct you on how to file an office complaint. All complaints must be submitted
in writing, and all complaints shall be investigated, without repercussion to you. You will not be penalized for
filing a complaint.
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, unless those uses can be reasonably inferred from the intended
uses above. If you have provided us with your permission to use or disclose medical information about you,
you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or
disclose medical information about you for the reasons covered by your written authorization. You understand
that we are unable 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 we provided to you.
PATIENT RIGHTS. THIS GIVES A GENERAL DESCRIPTION OF YOUR RIGHTS AND THE OBLIGATIONS OF
THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
You have the following rights regarding medical information we maintain about you Right to Inspect and Copy.
You have the right to inspect and copy medical information that may be used to make decisions about your
care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon
proof of an appropriate legal relationship, records of others related to you or under your care (guardian or
custodial) may also be disclosed. To inspect and copy your medical record, you must submit your request in
writing to our office. If you request a copy of the information, we may charge a fee for the costs of copying,
mailing or other supplies (tapes, disks, etc.) associated with your request. Right to Amend. If 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.
To 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. We 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: Was not
created by us, unless the person or entity that created the information is no longer available to make the
amendment; Is not part of the medical information kept by or for the Practice; Is not part of the information
which you would be permitted to inspect and copy; Is inaccurate and incomplete.
Right to an Accounting of Disclosures.
You 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. To 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. 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.
Right to Request Restrictions. You 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.
We 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 except that we shall not comply, even with a written request, if the
information is expected from the consent requirement or we are otherwise required to disclose the information
by law.
To request restrictions, you must make your request in writing. In your request, you must indicate: What
information you want to limit; Whether you want to limit our use, disclosure or both; To whom you want the
limits to apply (e.g., disclosure to your children, parents, spouse, etc.).
Right to Request Confidential Communications. You 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 the like. To 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.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice. You may ask to give you a copy of this notice at any time.
For any questions or concerns regarding this Notice of Privacy Practices you may contact our Compliance
Assistant, Jennifer Bones at 941-625-1325 Ext. 152.
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