Northwest Vision Institute

Notice of Privacy Practices for
Protected Health Information

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.

Northwest Vision Institute and our providers respect your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, and treatment, health information from other providers, and billing and payment information relating to those services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment and Health Operations.

For Treatment

Information obtained by a nurse, physician, or other member of our health team will be recorded in your medical record and used to help decide what care may be right for you.

We may also provide information to others providing you care. This will help them stay informed about you.

Necessary information obtained by our staff may be provided to outside laboratories, hospitals and clinics who will work with us to provide your care.

For Payment

We request payment from your health insurance plan. Health plans need information from us about your medical care, such as diagnoses, treatment rendered or other recommended care.

For Health Care Operations

We may use your medical records to assess quality and improve services.
We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
We may contact you to remind you about appointments and give you information about treatment alternatives or other health related benefits
We may contact you for marketing purposes
We may use and disclose your information to conduct or arrange for services, including:
- medical quality review by your health plan
- accounting, legal, risk management and insurance services
- audit function functions including fraud and abuse detection and compliance programs
- lab tests, surgeries and referred appointments to other providers

Your Health Information Rights

The health and billing records we create and store are the property of Northwest Vision Institute. The protected health information in it however, generally belongs to you. You have a right to:

Receive, read and ask questions about this notice;
Ask us to restrict certain uses and disclosures. You must deliver this request to us in writing. We are not required to grant the request, but we will comply with any reasonable request;
Request and receive from us a copy of the most current Notice of Privacy Practices for Protected Health Information.
Request that you be allowed to see and get a copy of your protected health information. You must make this request in writing. We have a form available for this type of request. There is no charge for the first copy but there is a charge for each additional copy.
Have us review a denial of access to your health information-except in certain circumstances;
Ask us to change your health information. You must give us this request in writing. You may also write a statement of disagreement if your request is denied. It will be stored in your medical record and may also be included with any release of your records.
When you request it, you will be given a list of disclosures of your health information. The list will not include disclosures to third party payors. You may receive this information without charge, once every twelve (12) months. We will notify you of the costs involved if you request this information more often.
Ask that your health information be given to you by another means or at another location. Please sign, date and give us your request in writing.
Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect ay action taken before we have it on file. You cannot cancel an authorization if its purpose was to obtain insurance.

Our Responsibilities:
We are responsible to

Keep your protected health information private
Give you this notice
Follow the terms of this notice

We have the right to change our practices regarding the protected health information we maintain. If we make changes we will update this notice. You may receive the most recent copy of it by asking for it.

To ask for Help or to Complain

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to our Clinic Director. You may also file a complaint with the U.S. Secretary of Human Services. If you complain, we will not retaliate against you.

If you have questions, want more information or wish to report a problem or concern about the handling of your protected health information, you may contact our Clinic Director at:

Northwest Vision Institute
12301 NE 10th #200
Bellevue, WA 98004

Other Disclosures and Uses of Protected Health Information/Notification of Family and Others

Without your express written authorization, we will not release health information about you to spouses, friends or family members. An exception will be if you are unable to make decisions for yourself and have a guardian overseeing your medical care. In addition, we may disclose health information about you to assist in disaster relief efforts.

We may use and disclose your protected health information without your authorization as follows

With Medical Researchers-if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
To Funeral Directors/Coroners consistent with applicable law to allow them to carryout their duties.
To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store or transplant organs.
To the Food and Drug Administration (FDA) relating to problems with food, supplements and other products.
To Comply with Workers' Compensation Laws-if you make a workers' compensation claim.
For Public Health and Safety Purposes as Allowed or Required by Law-to prevent or reduce a serious or immediate threat to the health or safety of an individual or the public. To prevent or control disease, injury, or death.
For Law Enforcement Purposes-to respond to a court order or other legal process or to report suspected abuse or neglect to public authorities.
For Specialized Government Agencies and Functions- we may share health information with the Dept. of Health, branches of the military or other agencies as allowed or required by law or with your written authorization.

Effective Date: April 14, 2003
Revised Date: April 10, 2007

Michael L. Gilbert, M.D.

Allen M. Rossman, M.D.

William W. Waugh, D.O.

Stephanie K. Kitamura, O.D.

Re-order contacts.

Phone

Fax

NWVISION@NWVISION.COM

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