Montrose Vision • 16750 S. Townsend Ave • Montrose, CO • 81401
NOTICE OF PRIVACY PRACTICES
This notice describes how your information can be used, disclosed, and how it can be accessed.
Your health information is used for these purposes:
TREATMENT: We will use and disclose your health information to provide, coordinate, and manage your health care and any related services. This includes setting up an appointment, testing and examining you, prescribing glasses and/or contacts, faxing a prescription to be filled, showing you low vision aids, referring you to another doctor or clinic for eye care or services or getting copies of your health information from another professional.
PAYMENT: We will use your health information to obtain payment for your health care services. This includes asking you about your health or vision care plans, or other sources of payment; preparing and sending bill or claims and collecting unpaid amounts.
HEALTH CARE OPERATIONS: We will use and disclose your health information in order to perform the business activities of this practice. These activities include, but are not limited to: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; legal manners; business planning ; outside storage of our records; calling you by name in the waiting room and contacting you to remind you of an appointment.
YOUR HEALTH INFORMATION CAN BE USED WITHOUT YOUR PERMISSION: We may use or disclose your health information with out your authorization in the following situations: where state or federal law mandates; health related research; health care operations; public health issues; communicable diseases; health oversight; abuse, violence, or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; medical examiner; coroners; funeral directors; organ donation; research; business associates that perform health care operations for use; criminal activity; military activity and national security; workers’ compensation; inmates and the Department of Health and Human Services.
DISCUSSIONS IN THE OFFICE: If you ask a question we will assume you wish to have it answered in the location where it is asked unless you request additional privacy. Unless you object, we will share information about your care with your family or friends who are helping you with your eye care.
APPOINTMENT REMINDERS: We may call or write to remind you of a scheduled appointment, treatments or services that might be helpful. Unless you tell us otherwise, we will do so by writing you and/or leave you a message on your answering machine or with someone who answers your phone if you are not home.
WE WILL NOT MAKE OTHER USES OR DISCLOSURES OF YOUR HEATLH INFORMATION UNLESS YOU SIGN A WRITTEN AUTHORIZATION FORM: You may revoke your authorization at any time. Revocations must be in writing and sent to the address at the top of this notice.
YOU RIGHTS ACCESS: You have the right to view and copy your health information. A valid request for release of records must be in writing and submitted to the address listed at the top of this notice. The request must include patient’s name, date of birth and signature, or signature of the patient’s authorized representative. A reasonable cost-based fee is charged for copying and mailing. After the request has been received, we have 15 business days to provide you with the information. We may deny your request in certain limited circumstances. If you are denied access to your health information, a written explanation will be provided.
REQUEST RESTRICTION OF INFORMATION (EXCEPT FOR EMERGENCY TREATMENT): You may request that we neither use no disclose any part of your protected health information for the purposes of treatment and/or payment of healthcare operations. You may also request your health information not be disclosed to family or friends that are involved in your care. Your written request must state the specific restriction requested, and to whom you want the restriction to apply. We are not required to agree to a restriction.
AMEND YOUR INFORMATION: If you think your information is incorrect or incomplete, send a written request, including your reasons for the amendment, to the address stated above. If we agree, we will amend the information within 60 days from when the request was received.
LIST OF DISCLOSURES: You have the right to receive a list of the disclosures we have made. In order to receive this list, a written request must be sent to the address listed at the top of this notice. By law, this list will no include all disclosures.
GET ADDITIONAL COPIES OF THIS NOTICE OF PRIVACY PRACTICES UPON REQUEST: We reserve the right to change this notice at any time as allowed by law. If changes are made, the new notice will be posted and available in our office.
QUESTIONS & COMPLAINTS: If you have questions or would like more information about our privacy practices, please contact us in writing at the above address. If you feel we have violated your privacy rights, you may submit a written complain to us and we will respond promptly.
PRIVACY OFFICER: Dr. Buchanan
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