NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices (“Notice”) describes how we may use or disclose your health information and how you can get access to such information. Please read it carefully. Your “health information,” for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as “health information” in this Notice).
We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.
USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION
The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
Other Disclosures and Uses We May Make Without Your Authorization or Consent
In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
- when a state or federal law mandates that certain health information be reported for a specific purpose;
- for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
- disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- uses or disclosures for health related research;
- uses and disclosures to prevent a serious threat to health or safety;
- uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
- disclosures of de-identified information;
- disclosures relating to worker’s compensation programs;
- disclosures of a “limited data set” for research, public health, or health care operations;
- incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- disclosures to “business associates” and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA;
- [specify other uses and disclosures affected by state law].
Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for heath care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.
SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosures we may not make of your health information without your authorization:
Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also include consent to such payment.
Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so.
Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.
YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES
- Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.
- You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.
- We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.
- We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).
Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.
YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
- To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.
- To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.
- To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
- To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information:
- was not created by us, unless the person that created the information is no longer available to make the amendment,
- is not part of the health information kept by or for us,
- is not part of the information you would be permitted to inspect or copy, or
- is accurate and complete.
- To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically).
- To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.
Our contact person for all questions, requests or for further information related to the privacy of your health information is noted below (Privacy Contact Officer).
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown above. If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area or can be downloaded as a PDF.
Consent to Telehealth Services and Riz Eye Care Policies
This form describes Riz Eye Cares Telehealth treatment alongside a Optometric Assistant (Provider), payment policies, and includes:
- Your consent to receive medical treatment from Riz Eye Care (and your other rights and responsibilities);
- Your agreement to receive services using tele-health technology along side a credentialed Optometric Assistant; and
- Your agreement to pay in full any charges that are your responsibility.
I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms of this Consent, including the terms of Riz Eye Care’s Privacy Notice described below.
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.
- By accepting to receive treatment at Riz Eye Care, I agree to receive telehealth services and be assessed by an Optometric Assistant. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications alongside our Optometric Assistant. During my visit, I have the option to visit with a State Licensed Optometrist and I will be able to see and speak with each other from remote locations.
- I understand and agree that:
- I will be in the room with a provider and upon request a state licensed optometrist will be available via tele-health.
- Riz Eye Care is licensed in the state in which I am receiving services. I will report my location accurately during online registration.
- Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to Riz Eye Cares provider’s office; (ii) more efficient medical evaluation and management; (iii) opportunity to visit any of Riz Eye Cares locations and still receive the same medical evaluation with a lead Optometrist, (iiii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
- Potential limitations of telehealth include: (i) limited or no availability of diagnostic testing and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Riz Eye Care responsible for lost information due to technological failures.
- I further understand that Riz Eye Cares advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that Riz Eye Care relies on information provided by me before and during our telehealth/ aided encounter and that I must provide information about my medical history, condition(s), and current or previous medical care/ ocular health that is complete and accurate to the best of my ability.
- I may discuss these risks and benefits with my provider at Riz Eye Care and will be given an opportunity to ask questions about telehealth services. I reserve the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to receive future treatment by Riz Eye Care and their providers.
- I understand that the level of care provided by my Provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest Riz Eye Care clinic, hospital emergency department or other appropriate health care provider.
- I have the right to receive face-to-face medical services at any time by traveling to a Riz Eye Care Clinic that is convenient to me.
- In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
- I consent to, understand and agree that:
- I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
- Riz Eye Care will provide care consistent with the current standards of medical practice but makes no assurances or guarantees as to the results of treatment.
- I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Riz Eye Cares standard policies regarding request and receipt of medical records and applicable law.
- The laws of the state in which I am located will apply to my receipt of telehealth services.
HIPAA (“Privacy Notice”)
Riz Eye Care will protect the privacy of my health information and will not use or disclose it except as permitted by law. Patient First’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: www.rizeye.com. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Patient First’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services and services rendered by our Optometric Assistant.
I acknowledge, understand and agree that:
- It is my responsibility to determine whether Riz Eye Care services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.
- I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.
- I assign Riz Eye Care all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to Riz Eye Care.
- If I have health care benefits, Riz Eye Care will submit a claim to my insurer and allow 90 days for reimbursement. If my insurer does not respond within 90 days, Riz Eye Care will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.
- By providing my credit card information and receiving telehealth services, I (i) authorize Riz Eye Care to charge my credit card for any and all unpaid amounts that my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Riz Eye Care may charge my credit card for such amounts before my telehealth visit or after my visit with the Optometric’s Assistant.
- I will be billed for all unpaid balances deemed by Riz Eye Care or my insurer to be my responsibility and agree to pay such amounts in full.
- Riz Eye Care may charge a fee for medical records. The fee will not exceed $25.00
- Riz Eye Care reserves the right to deny services if my account is delinquent.
I have been made aware on our practices intake form that a copy of this policy is available and my signature serves as cosntent to treatment. I may access and print a copy of this Consent here: www.rizeye.com
Privacy Contact Officer: Dr. Rizwan Jaffer