NOTICE OF PRIVACY POLICY – NORTH DAKOTA EYE CLINIC

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

Uses and Disclosures

Treatment. Your health information may be used by staff members and disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.

Payment. Your health information may be used to seek payment from your health plan, such as Medicare, Blue Cross Blue Shield of ND or MN, and other third party payers.

Public Health Reporting. Your health information may be disclosed to public health agencies as required by law. Also, your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

Appointment reminders. Your health information will be used by our staff to send you appointment reminders.

Disclosure of your health information or its use for any other purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a disclosure, you may submit a written revocation of the authorization.

Individual Rights

You have certain rights under federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your health information.
• The right to receive confidential communications concerning your medical condition and treatment.
• The right to inspect and receive copies of your health information.
• The right to amend or submit corrections to your health information.
• The right to receive an accounting of how and to whom your health information has been disclosed.
• The right to receive a printed copy of this notice.

North Dakota Eye Clinic Responsibilities

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy polices that are outlined in this notice. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. You may review or receive copies of your protected health information. As permitted by federal regulations, we require that requests to review or receive copies of your records be submitted in writing. Forms to request information may be obtained from the Privacy Officer.

Comments or Complaints

If you would like to submit a comment or complaint about our privacy practices, you may do so by sending a letter outlining your concerns to:

Ross J. Gonitzke, Administrator/Privacy Officer
North Dakota Eye Clinic
3035 DeMers Avenue, Grand Forks, ND 58201