Notice of Privacy Practices

Our pledge to you:

We understand that medical information about you and your health is personal and we are committed to protecting privacy while providing quality care. This Notice of Privacy Practices applies to all records generated by Dakota Eye Institute and Dakota Eye Institute Surgery Center, including departments, medical staff, clinics, employees and affiliated programs and services.

This notice describes how medical information about you may be used and disclosed and how you can access this informa­tion. Please review it carefully.

We are legally required to protect the privacy of your health in­formation. We call this information “protected health informa­tion,” or PHI, and it includes information that can be used to identify you that we have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment for health care services. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure.

We reserve the right to change the terms of this notice and our privacy policies. Any changes will apply to the PHI which is currently in our possession. Before we make an important change to our policies, we will promptly change this notice and post a new notice in our main reception areas. You can also request a copy of this notice from our Privacy Officer (701) 222-3937 or you may obtain a copy of the notice from our website at www.dakotaeye.com.

How we may use and disclose your PHI

We use and disclose PHI for a few different reasons. For some of these uses or disclosures, we need your written authorization. Below, we describe the different categories of our uses and disclosures and give you some examples.

Effective date of this notice

April 14, 2003.

Uses and disclosures which do not require authorization

We may use and disclose your PHI without your authorization for the following reasons:

For treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or to others providing you care. For example, if you are being treated for an eye disorder we may disclose your PHI to the facility doing the special testing in order to coordinate your care.

For payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provide to you.

For health care operations. We may disclose your PHI in order to operate this clinic. For example, we may use your PHI in order to evaluate the performance of the health care professional who provided health care services to you. We may also provide your PHI to our accountants, attorney, consultants, and others in order to make sure we are comp[lying with the laws that affect us.

For disclosure. When a disclosure is required by federal, state or local law, judicial or administrative proceedings, or law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot or other wounds; or when ordered in a judicial or administrative proceeding.

For public health activities. For examples, we report information about births, deaths, and various diseases, to government officials in charge of collecting that information. We may provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death.

For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.

For purpose of organ donation. We may notify organ procurement organizations to assist them in organ, eye, or tissue donation or transplants.

For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.

To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. We may disclose PHI to law enforcement agencies. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.

For Workers’ Compensation purposes. We may provide PHI in order to comply with workers’ compensation laws.

Appointment reminders and health related benefits of services. We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer.

Three uses and disclosures require you to have the opportunity to object

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment of your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

Other uses of health information. In any other situation, not described in this notice, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing to stop any future uses and disclosures (to the extent that we have not taken any action relying on the authorization).

Paid for services, “out of pocket.” If you have paid for services “out of pocket’, in full, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

What rights you have regarding your PHI

You have the following rights with respect to your PHI:

The right to request limits on uses and disclosures of PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.

The right to choose how we send PHI to you. You have the right to ask that we send information to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). We must agree to your request as long as we can easily provide it in the format you requested.

The right to inspect and copy your PHI. In most cases, you have the right to look at, or copies of, your PHI that we have. This may be written or electronic copy. If we do not have your PHI but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your request. In certain situations, we may deny your request. If we do, we will tell you, in writing, what our reasons are for the denial and explain your right to have the denial reviewed.

If you request copies of your PHI. There will be no charge for the first set of copies. Beginning the second set, we will charge 75¢ per page. Instead of pro­viding the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to this method. If you prefer an electronic copy (flash drive) there will be a $10 charge; an email copy is free.

The right to get a list of disclosures we have made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclo­sures for: treatment, payment or healthcare operations; information which you have authorized us to disclose; nation­al security; law enforcement as required by state or federal law; information released prior to January 2008.

We will respond within 60 days of receiving your request. The list we give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the infor­mation disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you $25 for each additional request.

The right to correct or update your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may deny your request in writing if the PHI is: 1) correct and complete, 2) not created by us, 3) not allowed to be disclosed, or 4) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. Your rights allow you to have your request and our denial attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.

HIPAA notice of security breach. If Dakota Eye Institute determines that a breach of unsecured protected health information has occurred, we will provide notice to the individual(s) without unreasonable delay, but no later than 60 days after the discovery of the breach.

The right to get this notice by email. You have the right to get a copy of this notice by email. Even if you have agreed to receive this notice by email, you also have the right to request a paper copy of this notice.

For more information or to report a problem

If you have questions and/or would like additional informa­tion regarding any rights included in this Notice of Privacy Practices, you may contact the Privacy Officer at (701) 222-3937.

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer by dialing (701) 222-3937, or writing to:

Dakota Eye Institute
Privacy Officer
200 S. 5th Street
Bismarck, ND 58504

You may also contact the US Secretary of Health and Human Services at 1-877-696-6775, or email OCRPrivacy@hhs.gov. For complaints involving covered entities located in Colorado, Montana, North Dakota, South Dakota, Utah , or Wyoming: Region VIII, Office for Civil Rights, US Department of Health and Human Services, 1961 Stout Street – RM 1185 FOB, Denver, CO 80294-3538. Voice phone 303-844-2024. Fax 303-844-2025. TDD 303-844-3439. There will be no retaliation for filling a complaint.