Cleveland Eye

and

Laser Surgery Center

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.

Cleveland Eye and Laser Surgery Center provides ambulatory surgical services. Due to the nature of these services, we are required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. We are also required to abide by the terms of the version of this Notice currently in effect.

Uses and Disclosures of PHI: We may use PHI for the purposes of treatment, payment, and health care operations, in most cases without your written permission. Examples of our use of your PHI:

• For Treatment. This includes such things as obtaining verbal and written information about your medical condition and treatment from you as well as from others, such as doctors and nurses who give orders to allow us to provide treatment to you. We may give your PHI to other health care providers involved in your treatment, and may transfer your PHI via radio or telephone to the hospital or dispatch center.
• For Payment. This includes any activities we must undertake in order to get reimbursed for the services we provide to you, including such things as submitting bills to insurance companies, making medical necessity determinations and collecting outstanding accounts.
• For Health Care Operations. This includes quality assurance activities, licensing, and training program to ensure that our personnel meet our standards of care and follow established policies and procedures, as well as certain other management functions.
• Reminders for Scheduled Procedures and Information on Other Services. We may also contact you with a reminder of any scheduled appointments for surgical or laser procedures, or to inform you about other services we provide.
• Use and Disclosure of PHI Without Your Authorization. We are permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law, including:

1. For the treatment, payment, or health care operations activities of another health care provider who treats you;
2. For health care and legal compliance activities;
3. To a family member, other relative, or close personal friend or other individual involved in your care if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection, and in certain other circumstances where we are unable to obtain your agreement and believe the disclosure is in your best interests;
4. To a public health authority in certain situations as required by law (such as to report abuse, neglect or domestic violence);
5. For health oversight activities including audits or government investigations, inspections, disciplinary proceedings, and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system;
6. For judicial and administrative proceedings as required by a court or administrative order, or in some cases in response to a subpoena or other legal process;
7. For law enforcement activities in limited situations, such as when responding to a warrant;
8. For military, national defense and security, and other special government functions;
9. To avert a serious threat to the health and safety of a person or the public at large;
10. For workers’ compensation purposes, and in compliance with workers’ compensation laws;
11. To coroners, medical examiners, and funeral directors for identifying a deceased person, determining cause of death, or carrying on their duties as authorized by law;
12. If you are an organ donor, we may release health information to organizations that handle organ procurement of organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ donation and transplantation;
13. For research projects, but this will be subject to strict oversight and approvals;
14. Use or disclose health information about you in a way that does not personally identify you or reveal who you are;
15. Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization. You may revoke your authorization at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that authorization.

Patient Rights: As a patient, you have a number of rights with respect to you PHI, including:

• The right to access, copy, or inspect your PHI. This means you may inspect and copy most of the medical information about you that we maintain. We will normally provide you with access to this information within 30 days of your request. We may also charge you a reasonable fee, as state law permits to provide a copy of any medical information you have the right to access. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials. We have forms available to request access to your PHI and we will provide a written response if we deny you access and let you know your appeal rights. You also have the right to receive confidential communications of your PHI. If you wish to inspect or obtain a copy of your medical information, you should contact our local privacy representative.
• The Right to Amend Your PHI. You have the right to ask us to amend written medical information we may have about you. We will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information only in certain circumstances, like when we believe the information you have asked us to amend is correct. If you wish to request an amendment of the medical information we have about you, please contact our local privacy representative to obtain an amendment request form.
• The Right to Request an Accounting. You may request an accounting from us of certain disclosures of your medical information we have made in the six years prior to the date of your request. However, your requests for an accounting of disclosures cannot precede the implementation date of HIPAA April 14, 2003. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment, or health care operations, or when we share your health information with our business associates, such as our billing company or a medical facility from/to which we have transported you. We are also not required to give you an accounting of our uses of PHI for which you have already given us written authorization. If you wish to request an accounting, contact our local privacy representative.
• The Right to Request That We Restrict the Uses and Disclosures of Your PHI. You have the right to request that we restrict how we use and disclose your medical information we have about you. We are not required to agree to any restrictions you request, but any restrictions agreed to by us in writing are binding on us.
• Right to Obtain a Paper Copy of the Notice on Request. If you would like a paper copy of this Notice, you may contact us at the address listed below and we wills provide you a paper copy of the Notice upon request.

Revisions to the Notice: We reserve the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all PHI we maintain. Any material changes to the Notice will be promptly posted in our facilities. You can get a copy of the latest version of this Notice by contacting our privacy official.

Your Legal Rights and Complaints: You have the right to file a complaint with the Ohio Department of Health. The Ohio Department of Health is the responsible agency for ambulatory surgical center’s complaint investigation. Complaints may be registered with the department by phone, 800-342-0553 or in writing to the Ohio Department of Health, PCSU, Second Floor, 246 North High Street, P.O. Box 118, Columbus, Ohio, 43216-0118. A complainant may provide his/her name, address, and phone number to the Department. Anonymous complaints may be registered. All complaints are confidential.

You also have the right to complain to us, or the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or to the government. Should you have any questions, comments, or complaints you may direct all inquiries to our privacy official.

Jeannine Arcuri

Administrator

Cleveland Eye and Laser Surgery Center

22715 Fairview Center Drive

Fairview Park, OH 44126