Notice of Privacy Practices for Protected Health Information
Effective Date: May 11, 2017
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: Privacy Officer at 888-308-4703, email@example.com or Legal Department 18501 Maple Creek Drive, Suite 400, Tinley Park, Illinois 60477.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its related rules and regulations dictate the privacy practices that health care organizations and their partners are obligated to follow with respect to medical information about you.
The law requires us to: (1) keep medical information about you confidential, as provided for by state and federal law; (2) notify you of our legal duties and privacy practices with respect to medical information about you; and (3) abide by the terms of our most current version of this notice.
Uses and Disclosures of Medical Information about You:
The following is a list of ways in which we may use and disclose medical information about you. We may:
In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing your medical information. If you chose to authorize use or disclosure you can later revoke that authorization by notifying us in writing of your decision.
Some states have separate privacy laws that may apply additional legal requirements regarding uses and disclosures of medical information about you. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.
Your Consent: By choosing to use our system and related sites and applications, you consent to the following:
- Processing of your image for use within our sites and applications.
- Receiving periodic text messages regarding your benefit and applicable products.
- Store your prescription, and contained information therein, for the purposes of making your eyewear. Eyelation stores your provider’s information, and may contact your provider to confirm details about your prescription. Eyelation maintains a database of providers and their contact information, and may use that information for other purposes.
To exercise these rights, contact our Privacy Officer to obtain a form or submit a written request to: 18501 Maple Creek Drive, Suite 400, Tinley Park, Illinois 60477. You have the right to:
- Inspect and obtain a copy of the medical information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain circumstances. If you are denied access to medical information about you, you may request that the denial be reviewed. We may charge you for the cost of the request.
- Request that we amend the information kept by us if you believe it is incorrect or incomplete. You must provide a reason that supports your request. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial and permitted to provide a statement of disagreement that will be attached to your medical record.
- Request an accounting of disclosures. This is a list of certain disclosures we make of medical information about you for purposes other than treatment, payment, or health care operations when an authorization was not required. Your request must specify a time period, which may not be longer than six years.
- Request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations and to limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request, except in the case of a disclosure to a health plan if it is for payment or certain care operations and relates to an item or service for which you have paid out of pocket in full. If we agree, we will comply with your request except in certain emergency situations or as required by law.
- Request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at work instead of home or vice versa. We will grant reasonable requests.
- A paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. Receive notification of breaches of unsecured medical information.
- You reserve the right to have any personal information, files, and images removed from our records.
Changes to this Notice:
We reserve the right to change this notice at any time, and the revised or changed notice will be effective for information we already have about you as well as any information we may receive in the future. The current notice will be posted on our website www.eyelation.com or upon request.
You have to file a complaint if you believe your privacy rights have been violated. You may register complaints with our Privacy Officer at the location above, who will evaluate the complaints and take appropriate action consistent with our mitigation and disciplinary policies.
You will not be retaliated against for filing a complaint. You also have the right to contact the Office for Civil Rights (OCR), who is the federal agency that enforces HIPAA rules and regulations.
Information on filing a complaint with OCR is available at http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html