Revised 12/15 – NATIONWIDE VISION & U.S. VISION PROFESSIONAL SERVICES & OPTICAL DEPARTMENT
THIS NOTICE DESCRIBES HOW YOUR OPTICAL PRESCRIPTION AND HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
OUR LEGAL DUTY – We are required by the federal Health Insurance Portability and Accountability Act of 1996 and any applicable state laws to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you at your next visit or it can be viewed in the store or on our Web site. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION – We use optical prescriptions & health information about you for treatment (including eye examinations & the ordering of prescription eyewear), to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care/service that you receive. Your health information is contained in a medical or optical dispensary record that is the physical property of Nationwide/U.S. Vision or an associated independent eye doctor.
How We May Use or Disclose Your Health Information
For Treatment. We may use or disclose your health information to an optometrist, ophthalmologist, optician or other healthcare providers providing treatment to you for:
- the placement of orders for prescription eyewear
- the provision, coordination, or management of health care and related services by health care providers;
- consultation between health care providers relating to a patient/customer or
- the referral of a patient for health care from one health care provider to another; or
- appointment reminders and recall information.
For Payment. We may use and disclose your health information to others for purposes of processing and receiving payment for treatment and services provided to you. This may include:
- billing and collection activities and related data processing;
- actions by a health plan or insurer to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims;
- medical necessity and appropriateness of care reviews, utilization review activities; and
- disclosure to consumer reporting agencies of information relating to collection of payments.
For Health Care Operations. We may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to:
- evaluate the performance of our associates;
- assess the quality of service, product and care in your case and similar cases;
- learn how to improve our facilities and services;
- conduct training programs or credentialing activities; and
- determine how to continually improve the quality and effectiveness of the products service, and care we provide.
Appointments, Treatment and Quality Assurance. We may use your information to provide appointment reminders or recall notices (such as voicemail messages, postcards or letters) or information about treatment alternatives or other health-related benefits, products and services that may be of interest to you. We may also contact you to conduct our own surveys about the quality of the products and services we provide.
To You, Your Family and Friends. We must disclose your health information to you, as described in the Your Health Information Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.
Persons Involved in Care. We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location or your general condition. If you are present prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled Rxs, medical supplies, photos, or other similar forms of health information.
Required by Law. We may use and disclose information about you as required by law. For example, we may disclose information for the following purposes:
- for judicial and administrative proceedings pursuant to legal authority;
- to report information related to victims of abuse, neglect or domestic violence;
- to assist law enforcement officials in their law enforcement duties; or
- to assist public health officials avert a serious threat to the health or safety of you or any other person.
Organ/Tissue Donation. Your health information may be used/disclosed for cadaveric organ, eye or tissue donation purposes.
Decedents. Health Information may be disclosed to funeral directors or coroners to for use in their lawful duties.
Research. We may use your health information for research purposes when an institutional review board or privacy board has reviewed & approved the research proposal and established protocols to ensure the privacy of your health information.
Government Functions. Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
Worker Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Worker Compensation.
Marketing Health Products or Services. We will not use your health information for marketing communications without your prior written authorization. We may, however, provide you with information regarding products or services that we offer related to your health care needs from our Optical, within the confines of this Notice of Privacy Practices. We will never sell your health information without your prior authorization.
Your Authorization. In addition to our use of your health information for treatment, payment or healthcare operations you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
YOUR HEALTH INFORMATION RIGHTS
Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You may be asked to make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost – based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice setting forth the specific information to which you desire access. If you request an alternative format, provided that it is practicable for us to produce the information in such format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosures made prior to April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request (in writing) that we amend your health information. Your request must explain why the information should be amended. We may deny your request under certain circumstances. You may obtain a form to request an amendment to your health information by using the contact information listed at the end of this Notice.
Electronic Notice: If you view this Notice on our website or by email, you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS – If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to exercise any of your legal rights under HIPAA, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
If you have any questions or complaints, please contact:
Privacy Office –Optical
1 Harmon Drive
Glendora, NJ 08029
Phone: 866-435-7111 Email: email@example.com
Thank you for entrusting us for your eye care and eyewear needs!