NOTICE OF PRIVACY PRACTICES
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.
I. What This Is
This Notice describes the privacy practices of Merrimack Eye
Clinic (the "Practice").
II. Our Privacy Obligations
We are required by law to maintain the privacy of medical and
health information about you (“Protected Health Information” or
“PHI”) and to provide you with this Notice of our legal duties and
privacy practices with respect to PHI. When we use or disclose
PHI, we are required to abide by the terms of this Notice (or
other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written
Consent or Authorization
In certain situations, which we will describe in Sections IV
and V below, we must obtain your written consent or authorization
in order to use and/or disclose your PHI. However, we do not need
any type of consent or authorization from you for the following
uses and disclosures:
A. Use For Treatment, Payment and Health Care Operations.
may use (but not disclose to a third party) your PHI in order to
treat you, obtain payment for services provided to you and conduct
our “health care operations” as detailed below:
We use PHI to provide treatment and other services
to you--for example, to diagnose and treat your injury or illness.
In addition, we may contact you to provide appointment reminders
or information about treatment alternatives or other
health-related benefits and services that may be of interest to
We may use PHI to obtain payment for services that
we provide to you--for example, to identify our claims for payment
from your health insurer, HMO, or other company that arranges or
pays the cost of some or all of your health care (“Your Payor”).
• Health Care Operations.
We may use PHI for our health care
operations, which include internal administration and planning and
various activities that improve the quality and cost effectiveness
of the care and customer service that we deliver to you. For
example, we may use PHI to evaluate the quality and competence of
our physicians, nurses and other health care workers, and we may
provide PHI to our office manager in order to resolve any
complaints you may have and ensure that you have a pleasant visit
B. Disclosure to Relatives, Close Friends and Other Caregivers.
We may disclose PHI, other than Highly Confidential Information
(described below in Section IV.B), to a family member, other
relative, a close personal friend, or any other person identified
by you when you are present for, or otherwise available prior to,
the disclosure, and do not object to such disclosure after being
given the opportunity to do so. We may also disclose your PHI to
such person with your verbal agreement or written consent.
If you are incapacitated or in an emergency circumstance, we
may exercise our professional judgment to determine whether a
disclosure is in your best interests. If we disclose information
to a family member, other relative or a close personal friend in
such circumstances, we would disclose only information that is
directly relevant to the person’s involvement with your health
care or payment related to your health care. We may also disclose
PHI in order to notify (or assist in notifying) such persons of
your location, general condition or death.
C. Public Health Activities.
We may disclose PHI for the
following public health activities:
1. to report health information to public health authorities
for the purpose of preventing or controlling disease, injury or
2. to report child abuse and neglect, elder abuse, disabled
persons abuse, or rape or sexual assault to public health
authorities or other government authorities authorized by law to
receive such reports;
3. to report information about products and services under the
jurisdiction of the U.S. Food and Drug Administration;
4. if we know or have reason to believe that you are infected
with a venereal disease, to alert: (a) your fiancée, if you are
engaged, or your spouse, if you are married, or (b) your parent or
guardian if you are a minor, unless as a minor you have sought
treatment with us for such venereal disease;
5. to report information to your employer and/or the
Massachusetts Industrial Accident Board as required under laws
addressing work-related illnesses and injuries or workplace
6. to report information related to the birth and subsequent
health of an infant to state government agencies as required by
7. to file a death certificate and report fetal deaths; and
8. to report abortions performed after 24 weeks of pregnancy to
state government agencies as required by law.
D. Health Oversight Activities.
We may disclose PHI to a health
oversight agency that oversees the health care system or
government benefit programs (such as Medicare or Medicaid).
E. Judicial and Administrative Proceedings.
We may disclose PHI
in the course of a judicial or administrative proceeding in
response to a legal order or other lawful process.
F. Law Enforcement Officials.
We may disclose PHI to the police
or other law enforcement officials as required or permitted by law
or in compliance with a court order or a grand jury or
We may disclose PHI to a coroner or medical
examiner as authorized by law.
H. Organ and Tissue Procurement.
If you are an organ donor, we
may disclose your PHI to organizations that facilitate organ, eye
or tissue procurement, banking or transplantation.
We may use or disclose PHI without your consent or
authorization for research purposes if an Institutional Review
Board/Privacy Board approves a waiver of authorization for such
use or disclosure.
J. Health or Safety.
We may use or disclose PHI to prevent or
lessen a serious danger to you or to others.
K. Specialized Government Functions.
We may use and disclose
PHI to units of the government with special functions, such as the
U.S. military or the U.S. Department of State under certain
circumstances required by law.
L. Ordered Examinations.
We may disclose PHI when required to
report findings from an examination ordered by a court or
M. As required by law
We may use and disclose PHI when
required to do so by any other law not already referred to in the
IV. Disclosures Requiring Your Written Consent
A. Disclosures For Treatment, Payment and Health Care
With your written consent, we may disclose PHI in
order to treat you, obtain payment for services provided to you
and conduct our health care operations as detailed below:
We may disclose PHI to provide treatment and other
services to you - - for example, we may disclose PHI to other
providers involved in your treatment.
We may disclose PHI to obtain payment for services
that we provide to you -- for example, disclosures to file claims
and obtain payment from Your Payor, or to verify that Your Payor
will pay for health care.
• Health Care Operations.
We may disclose PHI for our health
care operations. For example, we may disclose PHI in order to
resolve any complaints you may have and ensure that you have a
pleasant visit with us.
We may also disclose PHI to your other health care providers
when such PHI is required for them to treat you, receive payment
for services they render to you, or conduct certain health care
operations, such as quality assessment and improvement activities,
reviewing the quality and competence of health care professionals,
or for health care fraud and abuse detection or compliance.
B. Disclosures of Your Highly Confidential Information.
and state law require special privacy protections for certain
highly confidential information about you (“Highly Confidential
Information”), including: (1) your HIV/AIDS status; (2) genetic
testing information; (3) confidential communications with a
psychotherapist, psychologist, social worker, allied mental health
professional, or human services professional; (4) substance abuse
(alcohol or drug) treatment or rehabilitation information; (5)
venereal disease information; (6) abortion consent form(s); (7)
mammography records; (8) family planning services; (9) treatment
or diagnosis of emancipated minors; (10) mental health community
program records; and (11) research involving controlled
substances. In order for us to disclose your Highly Confidential
Information for a purpose related to treatment, payment, or health
care operations, we must obtain your separate, specific written
consent unless we are otherwise permitted by law to make such
In addition, if you are an emancipated minor, certain
information relating to your treatment or diagnosis may be
considered “Highly Confidential Information” and as a result will
not be disclosed to your parent or guardian without your consent.
Your consent is not required, however, if a physician reasonably
believes your condition to be so serious that your life or limb is
endangered. Under such circumstances, we may notify your parents
or legal guardian of the condition, and will inform you of any
Please note that if you are a parent or legal guardian of an
emancipated minor, certain portions of the emancipated minor’s
medical record (or, in certain instances, the entire medical
record) may not be accessible to you.
V. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization.
For any purpose
other than those described in Section III (for which no consent or
authorization is required) and Section IV (for which your consent
is required), we only may use or disclose your PHI when you give
us your written authorization on our authorization form
(“Authorization”) (an authorization form is similar to a consent
form, but is more detailed and specific than a general consent
form). For instance, you will need to provide us your signed
Authorization before we can send PHI to your life insurance
company, to your child’s camp or school, or to the attorney
representing the other party in litigation in which you are
involved (unless the attorney has obtained a court order for such
B. Uses and Disclosures of Your Highly Confidential
Please refer to Section IV.B above for information
about our use and disclosure of your Highly Confidential
Information. In order for us to disclose your Highly Confidential
Information for a purpose other than treatment, payment, or health
care operations (for which your separate, specific consent is
required), we must obtain your separate, specific Authorization,
unless we are otherwise permitted by law to make such disclosure.
C. Marketing Communications.
We must also obtain your written
authorization prior to using PHI to send you any marketing
materials (“Marketing Authorization”). We can, however, provide
you with marketing materials in a face-to-face encounter, without
obtaining your Marketing Authorization. We are also permitted to
give you a promotional gift of nominal value, if we so choose,
without obtaining your Marketing Authorization. In addition, we
may communicate with you about products or services relating to
your treatment, case management or care coordination, or
alternative treatments, therapies, providers or care settings
without your Marketing Authorization, and we may use PHI to
identify health-related services and products that may be
beneficial to your health and then contact you about the services
VI. Your Individual Rights
A. For Further Information; Complaints.
If you desire further
information about your privacy rights, are concerned that we have
violated your privacy rights or disagree with a decision that we
made about access to PHI, you may contact our Office Manager. You
may also file written complaints with the Director, Office for
Civil Rights of the U.S. Department of Health and Human Services.
Upon request, the Office Manager will provide you with the correct
address for the Director. We will not retaliate against you if you
file a complaint with us or the Director.
B. Right to Request Additional Restrictions.
You may request
restrictions on our use and disclosure of PHI: (1) for treatment,
payment and health care operations, (2) to individuals (such as a
family member, other relative, close personal friend or any other
person identified by you) involved with your care or with payment
related to your care, or (3) to notify or assist in the
notification of such individuals regarding your location and
general condition. All requests for such restrictions must be made
in writing. While we will consider all requests for additional
restrictions carefully, we are not required to agree to a
requested restriction. If you wish to request additional
restrictions, please obtain a request form from our Office Manager
and submit the completed form to the Office Manager. We will send
you a written response.
C. Right to Receive Confidential Communications.
request, and we will accommodate any reasonable written request,
to receive PHI by alternative means of communication or at
D. Right to Inspect and Copy Your Health Information.
request access to your medical record file and billing records
maintained by us in order to inspect and request copies of the
records. All requests for access must be made in writing. Under
limited circumstances, we may deny you access to your records. If
you desire access to your records, please obtain a record request
form from the Office Manager and submit the completed form to the
Office Manager. If you request copies, we will charge you $0.25
(twenty five cents) for each page. We will also charge you for our
postage costs, if you request that we mail the copies to you.
E. Right to Revoke Your Authorization.
You may revoke your
Authorization, your Marketing Authorization or any written
authorization obtained in connection with your Highly Confidential
Information, except to the extent that we have taken action in
reliance upon it, by delivering a written revocation statement to
the Office Manager identified below. A form of Written Revocation
is available upon request from the Office Manager.
F. Right to Amend Your Records.
You have the right to request
that we amend PHI maintained in your medical record file or
billing records. If you desire to amend your records, please
obtain an amendment request form from the Office Manager and
submit the completed form to the Office Manager. All requests for
amendments must be in writing. We will comply with your request
unless we believe that the information that would be amended is
accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures.
request, you may obtain an accounting of certain disclosures of
PHI made by us during any period of time prior to the date of your
request provided such period does not exceed six years and does
not apply to disclosures that occurred prior to April 14, 2003. If
you request an accounting more than once during a twelve (12)
month period, we will charge you $0.25 per page of the accounting
H. Right to Receive Paper Copy of this Notice.
request, you may obtain a paper copy of this Notice, even if you
agreed to receive such notice electronically.
VII. Effective Date and Duration of This Notice
A. Effective Date.
This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice.
We may change the
terms of this Notice at any time. If we change this Notice, we may
make the new notice terms effective for all PHI that we maintain,
including any information created or received prior to issuing the
new notice. If we change this Notice, we will post the revised
notice in waiting areas of the Practice and on our Internet site
at www.merrimackeyeclinic.com. You may also obtain any revised
notice by contacting the Office Manager.
VIII. Office Manager
You may contact the Office Manager at:
Merrimack Eye Clinic
1230 Bridge St., Lowell, MA 01850
Telephone Number: 978-452-2100 Ext 16