Your Privacy

Your Protected Health Information

How We May Use and Disclose your Medical Information

Changes to this Notice


Patient Rights



Notice of Privacy Practices


Date of Last Revision: September 10, 2013
Effective Date: Immediately

This notice describes Retina Consultants policies, which extend to:
• Any health care professional authorized to enter information into your chart
• All areas of the Practice
• All employees, staff and other personnel who work for or with Retina Consultants
• Our business associates (billing, on-call physicians, or facilities to which we refer)
Retina Consultants 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).


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 service we provide to you as our patient.

We are required by law to:
• Make sure 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
• Follow the conditions of the Notice that is currently in effect


How We May Use and Disclose Your Medical Information

Medical Treatment
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. We also may disclose medical information with family members or personal representatives authorized by you or by legal mandate.

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 also tell your health plan or referring physician about treatment you are going to receive to obtain prior approval or to determine if your health plan will cover the treatment.

Health Care Operations
We may use and disclose medical information about you to review our treatment and services and to evaluate the performance of our staff. We may also disclose information to doctors, nurses,technicians, medical students, and other personnel for review and learning purposes.

Appointment and Patient Recall Reminders
We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with Retina Consultants or that you are due to receive periodic medical care. This contact could be by phone, postcard, or by e-mail, which could potentially be received or intercepted by others.

We may use and disclose medical information about you for research purposes regarding medications or the efficiency of treatment protocols. We will obtain an authorization from you before using or disclosing your individually identifiable health information.

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 to you, the public or any other person.

Organ and Tissue Donation
We may release medical information to organizations to facilitate organ or tissue donation or
transplantation if you are an organ donor.

Marketing, Fundraising, and any purpose which would Constitute the Sale of your Information
These disclosures would require your written authorization. You may revoke this authorization at any time with a written request.

Any Other Uses or Disclosures
Any disclosures not otherwise described in this notice will be made only with your written authorization. You may revoke this authorization at any time with a written request, however, this revocation will not be effective for information we have used or disclosed in reliance on the authorization prior to the revocation.

Public Health Risks
Law or public policy may require us to disclose medical information about you for public health activities.
• To prevent or control disease
• To report births or deaths
• To report child abuse or neglect
• To notify people of recalls of products
• To notify a person who may have been exposed to a disease that would leave them at risk to contract or spread such disease
• To notify appropriate government authorities if we believe a patient has been the victim of abuse. We will only make this disclosure if you agree or when required by law.

Investigation and Government Activities
We may disclose medical information to a local, state or federal agency for activities authorized by law. These activities are necessary for the government and other regulatory agencies to monitor the health care system, government programs, and compliance with civil rights laws.

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. 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.

Coroners, Medical Examiners and Funeral Directors
We may release medical information to a coroner, medical examiner, or funeral director as necessary to carry out their duties.

If you are an inmate or under the custody of a law enforcement official, we may release medical information to:
• Provide you with health care
• Protect your health and safety and the health and safety of others
• Protect the safety and security of the correctional institution


Changes to this Notice

We reserve the right to change this notice at any time. We will post a copy of the current Notice in the Practice. The notice will contain on the first page, at the top, the date of the last revision and effective date.



If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services or the Office of Civil Rights at 401-222-4576. If you wish to file a complaint with Retina Consultants, contact our compliance officer, Erika Banalewicz, at 401-274-5844, who will help you with the procedure. All complaints must be submitted in writing, and all complaints will be investigated, without repercussion to you.


Patient Rights


Right to Inspect and Copy
You have the right to inspect and copy medical information used in making decisions about your care. You must submit your request in writing to our Compliance Officer. We will charge a$15.00 fee, and $.25 per page for the cost of copying, mailing, or other supplies associated with your request. A fee will also be charged for the copy of photographs.
We may deny your request to inspect and copy in very limited circumstances. If you are denied access to medical information, you may request that our Compliance Committee review the denial.

Right to Amend
If you feel the medical information we have about you in your record is incorrect or incomplete, you may ask us to amend the information. You must request an amendment in writing along with a reason that supports your request. This amendment must be dated, signed by you, and notarized.

We may deny your request for amendment if:
• it is not in writing or does not include a reason to support the request
• was not created by us, unless the entity that created the information is no longer available
to make the amendment
• is not part of the medical information kept by or for Retina Consultants
• is not part of the information you would be permitted to inspect or copy
• is inaccurate and incomplete

Right to an Electronic Copy of Electronic Medical Records
You have the right to request that an electronic copy of your medical records be given to you, or transmitted to another individual or entity, if they are maintained in an electronic format. We will make every effort to provide the copy in the format you request, however if it is not readily producible by us we will provide it in either our standard format or in a hard copy form. A fee may be charged.

Right to Notification
You have the right to receive notification following any breach of your unsecured personal health information.

Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of disclosures we made of medical information about you, to others. You must submit this 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 (or the actual implementation date of the HIPAA Privacy Regulations.)

We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

Right to Request Restrictions
You have the right to request restrictions or limitations 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.

We are not required to agree to your request and may not be able to comply with your request.

To request restrictions, you must make your request in writing. Please indicate:
• what information you wish to limit
• whether you want to limit our use, disclosure or both
• to whom you want the limits to apply

You have the right to request that we do not disclose your protected health information if you have paid, out of pocket, in full, for the services received, and we must comply, except in the rare event that it is required by law.

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: not at work or not to leave voice mail.) This must be requested in writing.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time.