Privacy Practice Notice

Notice of Privacy Practices for Intermountain Eye & Laser Centers

Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION – PLEASE READ CAREFULLY.

We are required by law to maintain the privacy of your health information and to give you notice of our legal duties and privacy practices with respect to your protected health information. This Notice summarizes our duties and your rights concerning your protected health information. Our duties and your rights are set forth more fully in 45 Code of Federal Regulations Part 164. We are required to abide by the terms of our Notice that is currently in effect.

Uses and Disclosures of Information We May Make Without Written Authorization: We may use or disclose protected health information for the following purposes without your written authorization. NOTE: These examples are not meant to be exhaustive.

• Treatment: We may use or disclose protected health information to provide treatment to you. For example, a physician or his/her staff may use information in your medical records to diagnose or treat your condition. In addition, we may disclose your information to health care providers outside our office so they may help treat you.
• Payment: We may use or disclose protected health information so that we or other health care providers may obtain payment for treatment provided to you. For example, we may disclose information from your medical records to your health insurance company to obtain pre-authorization for treatment or submit a claim for payment.
• Health Operations: We may use or disclose protected health information for certain health care operations that are necessary to run our practice and ensure that our patients receive quality care. For example, we may use information from your medical records to review the performance or qualifications of physicians and staff, train staff or make business decisions affecting our practice.
• Required by Law: We may use or disclose protected health information to the extent that such use or disclosure is required by law.
• Threat to Health or Safety: We may use or disclose protected health information to avert a serious threat to your health or safety, or the health and safety of others.
• Abuse or Neglect: We may use or disclose protected health information to the appropriate government agency if we believe it is related to child abuse or neglect, or if we believe that you have been a victim of abuse, neglect or domestic violence.
• Communicable Diseases: We are required to disclose protected health information concerning certain communicable diseases to the appropriate government agency. To the extent authorized by law, we may also disclose protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
• Public Health Activities: We may use or disclose protected health information for certain public health activities, such as reporting information necessary to prevent or control disease, injury or disability; reporting birth and deaths; or reporting limited information for FDA activities.
• Health Oversite Activities: We may use or disclose protected health information to governmental health oversite agencies to help them perform certain activities authorized by law, such as audits, investigations and inspections.
• Judicial and Administrative Proceedings: We may use or disclose protected health information in response to an order of a court or administrative tribunal. We may also disclose protected health information in response to a subpoena, discovery request or other lawful process if we receive satisfactory assurances from the person requesting the information that they have made efforts to inform you of the request or to obtain a protective order.
• Law Enforcement: We may use or disclose protected health information, subject to specific limitations, for certain law enforcement purposes including to identify, locate or catch a suspect, fugitive, material witness or missing person; to provide information about the victim of a crime; to alert law enforcement that a person may have died as a result of a crime; or to report a crime.
• National Security: We may use or disclose protected health information to authorized federal officials for national security activities.
• Coroners and Medical Examiners: We may use or disclose protected health information to a coroner or medical examiner to identify a deceased person, determine cause of death or permit the coroner or medical examiner to fulfill their legal duties.
• Organ Donation: We may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of cadaveric organs or tissue.

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• Research: Under certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols and the like. All research projects are subject to an approval process, which evaluates a proposed research project and its use of medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will obtain an authorization from you before using or disclosing your individually identifiable health information unless the authorization requirement has been waived. If possible, we will make the information non-identifiable to a specific patient. If the information has been sufficiently de-identified, an authorization for the use or disclosure is not required.
• Workers’ Compensation: We may use or disclose protected health information as authorized by workers’ compensation laws and other similar legally established programs.
• Appointment and Patient Recall Reminders: We may ask that you sign in writing at the Receptionist’s Desk, a “Sign-in” log on the day of your appointment with the practice. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with the practice or that you are due to receive periodic care from the practice. This contact may be by telephone, in writing, via e-mail, or otherwise, and may involve the leaving of an e-mail, a message on an answering machine or otherwise, which could (potentially) be received / intercepted by others.
• Marketing: We may use or disclose protected health information for limited marketing activities including face-to-face communication with you about our services.
• Business Associates: We may use or disclose protected health information to our third party business associates who perform activities involving protected health information for us, i.e. billing or transcription services. Our contracts with the business associates require them to protect your health information.
• Military: We may use or disclose protected health information as required by military command authorities.
• Inmates or Persons in Police Custody: If you are an inmate or in the custody of law enforcement, we may use or disclose protected health information if necessary for your health care; for the health and safety of others; or for the safety or security of the correctional institution.

Uses and Disclosures of Information We May Make Unless You Object: We may use and disclose protected health information in the following instances without your written authorization unless you object. NOTE: If you object, please notify the Privacy Contact (see last page).

• Facility Directories: Unless you object, we may disclose your location in our facility and your general condition to people who ask for you by name.
• Persons Involved in Your Health Care: Unless you object, we may use or disclose protected health information to a member of your family, relative, close friend or other persons identified by you who are involved in your health care or the payment for your health care. We will limit the disclosure to the protected health information relevant to that person’s involvement in your health care or payment.
• Notification: Unless you object, we may use or disclose protected health information to notify a family member or other person responsible for your care, location and condition. Among other things, we may disclose protected health information to a disaster relief agency to help notify family members.

Uses and Disclosures of Information We May Make With Your Written Authorization: We will obtain written authorization from you before using or disclosing your protected health information for purposes other than those summarized above. You may revoke your authorization by submitting a written notice to the Privacy Contact (see last page).

Your Rights Concerning Your Protected Health Information: You have the following rights concerning you protected health information. To exercise any of these rights, you must submit a written request to the Privacy Contact (see last page).

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• Right to Request Additional Restrictions: You may request additional restrictions regarding the use or disclosure of your protected health information for treatment, payment or health care operations. We are not required to agree to a requested restriction. If we agree to a restriction, we will comply with the restriction unless either an emergency or the law prevents us from complying with the restriction or until the restriction is terminated.
• Right to Receive Communications by Alternative Means: We normally contact you by telephone or mail at your home address. You may request that we contact you by some other method or at some other location. We will not ask you to explain the reason for your request. We will accommodate reasonable requests. We may require you to explain how payment will be handled if an alternative means of communication is used.
• Right to Inspect and Copy Records: You may inspect and obtain a copy of protected health information that is used to make decisions about your care or payment for your care. We may charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances, i.e. if you seek psychotherapy notes, information prepared for legal proceedings or if disclosure may result in substantial harm to you or others.
• Right to Request Amendment to Record: You may request that your protected health information be amended. You must explain the reason for your request in writing. We may deny your request if we did not create the record unless the originator is no longer available; if you do not have a right to access the record; or if we determine that the record is accurate and complete. If we deny your request, you have the right to submit a statement disagreeing with our decision and to have the statement attached to the record.
• Right to an Accounting of Certain Disclosures: You may receive an accounting of certain disclosures we have made of your protected health information after April 14, 2003. We are not required to account for disclosures regarding treatment, payment or health care operations; to family members or others involved in your health care or payment; for notification purposes; or pursuant to our facility directory or your written authorization. You may receive the first accounting within a 12-month period free of charge. We may charge you a reasonable cost-based fee for all subsequent requests during that 12-month period.
• Right to a Copy of this Notice: You have the right to obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically.

Changes to this Notice: We reserve the right to change the terms of our Notice of Privacy Practices at any time, and to make the new Notice provisions effective for all protected health information we maintain. If we materially change our privacy practices, we will prepare a new Notice of Privacy Practices, which shall be effective for all protected health information we maintain. We will post a copy of the current Notice in our reception area and on any website we may develop. You may obtain a copy of the current Notice in our reception area or by contacting the Privacy Contact identified below.

Complaints: You may complain to us or the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Contact identified below. All complaints must be in writing; we will not retaliate against you for filing a complaint.

Privacy Contact: If you have any questions about this Notice or if you want to object to or complain about any use or disclosure or exercise any rights as explained above, please contact:

Kathy R. Dodd, Office Manager

Intermountain Eye & Laser Centers

999 North Curtis Road, Suite 205

Boise, ID 83706

“ I am so thankful for Dr. Fishburn and the fine surgeries he performed on my eyes. I am so grateful to have clear vision and to have such a competent, caring doctor. It is wonderful that you are able and choose to help so many with their precious sight. Thank you to your staff for their professionalism and care. You made this experience so positive. ”