Tyler L. Schremmer O.D., P.A.

Notice of Privacy Practices

Effective September 23, 2013 (please review carefully)

We are permitted by federal laws to use and disclose your Protected Health Information (PHI) for purposes of treatment, payment, and health care operations. PHI is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examinations, test results, diagnoses, treatments, and plans for future care of services, as well as personal information such as your name, date of birth and social security number. With some exceptions, we will not use or disclose any more of your PHI than necessary to accomplish the purpose of the disclosure.

We are required by law to maintain the privacy of your PHI, to give you this notice and to make a good faith effort to obtain your acknowledgement of receipt of this notice. We reserve the right to amend, change or eliminate the provisions of this notice at any time. When we make an important change to our privacy policies, we will promptly change this notice and post the new notice in our reception area.

How May We Use and Disclose PHI

The law permits us to use or disclose PHI for treatment, payment, and health care operation. Examples of uses of PHI are:

• A. Treatment
• We will provide PHI to other physicians and their offices, to lens laboratories, contact lens suppliers, medical laboratories, pharmacies, imaging centers, hospitals, nursing homes, and others that are involved in your treatment.
• We may use or disclose your PHI in an emergency treatment situation.
• If a spouse, parent, son, daughter, other relative or friend is involved in your treatment, using our best judgement, we will share relevant PHI with them.
• We may call your home to remind you of your appointments or ask you to contact us. We may leave messages on your answering machines or with another person in your household about upcoming appointments or with requests that you contact us. We may send postcard reminders of appointment dates or missed appointments.
• B. Payment
• We submit insurance forms to health insurance companies, vision plans, third party processing companies, Workers Compensation insurers, motor vehicle insurers and other insurance entities. We will provide information to them about you and the care given.
• We may provide health information to your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
• In cases when we are unable to get payment for our charges from the patient or other responsible individual, we may send information about you to a collection agency or other debt collection service to secure payment from the individual responsible for payment of our charges.
• C. Health Care Operations
• Internally, our staff will obtain health information about you and record it in a health record.
• We may obtain services from insurers, attorneys, medical billing companies, transcriptionists, collection agencies, consultants, or other business associates for coding audits, quality improvement, operational improvements, transcription, clinical guidelines development, training programs, credentialing, medical review, legal services and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Other Possible Disclosures and Uses

• A. Notification
• Unless you object in writing, we may use or disclose your PHI to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
• B. Communication with Family or Friends
• Using our best judgement, we may disclose to a family member, other relative, close personal friend, or any other person you identify, PHI relevant to the person’s involvement in your care or in payment for such care. You may provide us with a written objection prohibiting us from sharing PHI with specific individuals.
• C. Organ Procurement Organizations
• Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• D. Food and Drug Administration (FDA)
• We may disclose to the FDA your protected PHI relating to adverse events with respect to food, supplements, products defects, or post-marking surveillance information to enable product recalls, repairs, or replacements.
• E. Workers Compensation
• If you are seeking services through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation
• F. Public Health
• As authorized by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.
• G. Abuse and Neglect
• We may disclose your PHI to public authorities as allowed by law to report abuse or neglect.
• H. Employers
• We may release your PHI to your employer if we provide health care services to you at the request of your employer or in cases involving Workers Compensation. Other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.
• I. Correctional Institutions
• If you are an inmate of a correctional institution, we may disclose to the institution or its agents the PHI necessary for your health and for the health and safety of others.
• J. Law Enforcement
• We may disclose your PHI for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.
• K. Health Oversight
• Federal law allows us to release your PHI to appropriate health oversight agencies or for health oversight activities.
• L. Judicial/Administrative Proceedings
• We may disclose your PHI in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
• M. Serious Threat
• To avert a serious threat to health or safety, we may disclose your PHI consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
• N. For Specialized Governmental Functions
• We may disclose your PHI for specialized government functions as authorized by law such as to Armed Forces Personnel, for national security purposes, or to public assistance program personnel.
• O. Deceased Persons Information
• We may release PHI to a coroner or medical examiner. This may be necessary for example, to identify a deceased person or determine the cause of death. We may also release PHI about patients to funeral directors as necessary for them to carry out their duties.
• P. Surveys
• We may use and disclose health information to conduct surveys to assess your satisfaction with our services.
• Q. The right of an individual
• To restrict disclosures of PHI to a health plan with respect to health care for which the individual has paid out of pocket in full for those services.
• R. Individuals have the right
• Individuals have the right to opt out of receiving fundraising communications from a covered entity that has stated the intent to fundraise in their notice.
• S. Other Uses
• Other uses and disclosures, besides those identified in this notice, will only be made as otherwise required by law or with your written authorization, and you may revoke the authorization as provided in this Notice under: Your Health Information Rights.

Your Health Information Rights

The health and billing records we maintain are the physical property of this office. The information in the record, however, belongs to you. You have a right to:

• A. Obtain a copy of this notice
• A paper copy of this Notice of Privacy Practices will be granted by making a verbal or written request at our office.
• B. Request a Restriction
• You may request a restriction on certain uses and disclosures of your health info by delivering the written to us. In your request you must tell us: 1) what info you want to limit 2) whether you want to limit our use, disclosure or both, and 3) to whom you want the limits to apply, for example, your spouse. We are not required to grant the request, but we will comply with any request granted.
• C. Inspect and copy
• You have the right to inspect and copy your health record and billing record. To inspect and copy your PHI, you must submit your request in writing to our office. If you request a copy of PHI, we may charge a fee for the cost of the copying, mailing, or other supplies and services associated with your request.
• D. Amend Health Information
• You have the right to request that your health care record can be amended to correct incomplete or incorrect info. To request that amendment, you must submit your request in writing and provide a reason that supports your request. We may deny your request if you ask us to amend information that: 1) Was not created by us, unless the person or entity that created the information is no longer available to make the amendment: 2) is not part of the health information kept by our office: 3) is not part of the information that you would be permitted to inspect and copy/or: 4) is accurate and complete. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement and be maintained with your records.
• E. Request Alternative Methods of Communication
• F. You have the right to request that we communicate with you about medical matters in a certain way at a certain location. For example, you may ask that we only contact you at work or by mail. To request alternative methods of communications, you must put the request in writing and deliver it to our office. Your request must be specific on how and where you wish to be contacted. We will accommodate all reasonable requests.
• G. Obtain an Accounting of Disclosures
• You have the right to request an ‘accounting of disclosures’ of your PHI. Any accounting will not include uses and disclosures of information of treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made to family members relevant to that person’s involvement in your care of your location, condition, or death. You must submit your request for accounting or disclosures in writing to our office. Your request must state the time period, which may not be longer than six years and may not include dates prior to ‘April 14th, 2003’. The first list you request in a 12 month period will be free. We may charge you the costs of providing additional lists.
• H. Revoke Previous Authorizations
• You have the right to revoke authorizations that you made previously to use or disclose authorizations that you made previously to use or disclose information by delivering written revocation to our office, except to the extent information has been disclosed or action has already been taken.
• Security Regulations- A prohibition on the sale of protected health information without express written authorization by the individual as well as a description of certain types and uses and disclosures that require patient authorization. (An example would include marketing or disclosure of psychotherapy notes).
• The duty of a covered entity is to notify affected individuals of a breach of unsecured protected health information. For health plans that underwrite, the prohibition against health plans using or disclosing PHI that has genetic information about an individual for underwriting purposes.

Additional Information or to File a Complaint

• A. If you have questions, would like additional information, or want to report a problem regarding the handling of your PHI, you may contact:

Tonya Strong

Privacy Officer

Tyler L. Schremmer O.D., P.A.

801 N. Pine St

Hoisington KS 67544

620-653-2748

• Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint address to Kelly Kaba and marked as ‘personal and confidential’. You may also file a complaint by mailing it to the OCR Headquarters, whose street address is:

Office for Civil Rights Headquarters

US Dept. of Health and Human Services 200 Independence Ave S.W.

Washington, DC 20201

• We cannot, and will not, require you to waive the right to file a complaint with the Office for Civil Rights as a condition of receiving treatment from the office. We cannot, and will not retaliate against you for filing a complaint with the Office for Civil Rights.
• B. Website
• If we maintain a website that provides information about our entity, this Notice will be on the website.
• C. Changes to this Notice
• We reserve the right to amend, change, or eliminate provisions of the Notice at any time. We reserve the right to make any revised notice effective for health information we already have as well as any information we receive in the future.
• D. Acknowledgement
• You will be asked to sign a written acknowledgement of your receipt of this Notice of Privacy Practices.