|
Welcome Forms
Please download and fill out the following forms: Please email completed forms back to [email protected].
|
HIPPA- Health Insurance Portability and Accountability Act
Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Bright Eyes Optometry can use your protected health information for treatment, payment and healthcare operations.
a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
b) Payment - We may use and disclose your health information to obtain payment for services we provide you.
c) Healthcare operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization
Most uses and disclosures that do not fall under treatment, payment, healthcare operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.
Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.
Marketing
We will not use your health information for marketing communications without your written authorization.
Required by Law
We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people's health or safety.
National Security
We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.
Appointment Reminders
We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.
Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations.
-You have the right to receive confidential communications regarding your protected health information.
-You have the right to inspect and copy your protected health information.
-You have the right to amend your protected health information.
-You have the right to receive an account of disclosures of your protected health information.
-You have the right to a paper copy of this notice of privacy practices.
Legal Requirements
Bright Eyes Optometry is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are available within our office.
Complaints
If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.
Contact Information
For further information about Bright Eye Optometry's privacy policies, please contact Dr. Janet Chan at the following address or phone number:
Bright Eyes Optometry
Janet Chan, OD, Inc
500 Alfred Nobel Dr. # 138
Hercules, CA 94547
510-724-1000
Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Bright Eyes Optometry can use your protected health information for treatment, payment and healthcare operations.
a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
b) Payment - We may use and disclose your health information to obtain payment for services we provide you.
c) Healthcare operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization
Most uses and disclosures that do not fall under treatment, payment, healthcare operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.
Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.
Marketing
We will not use your health information for marketing communications without your written authorization.
Required by Law
We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people's health or safety.
National Security
We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.
Appointment Reminders
We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.
Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations.
-You have the right to receive confidential communications regarding your protected health information.
-You have the right to inspect and copy your protected health information.
-You have the right to amend your protected health information.
-You have the right to receive an account of disclosures of your protected health information.
-You have the right to a paper copy of this notice of privacy practices.
Legal Requirements
Bright Eyes Optometry is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are available within our office.
Complaints
If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.
Contact Information
For further information about Bright Eye Optometry's privacy policies, please contact Dr. Janet Chan at the following address or phone number:
Bright Eyes Optometry
Janet Chan, OD, Inc
500 Alfred Nobel Dr. # 138
Hercules, CA 94547
510-724-1000