Insurance Information

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HIPAA Policy

Effective date of notice: April 1, 2003
NOTICE OF PRIVACY PRACTICES
Booth Optometry Group
1102 Irvine Blvd
Tustin, CA 92780
(714) 838-3210

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. THANK YOU

GENERAL RULE
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. Generally, we cannot use your health information in our office or disclose it outside of our office without your written permission. Sometimes the written permission will be called a consent form, and sometimes it will be called an authorization form. The type of permission form will depend upon the kinds of uses or disclosures that are involved. In some limited situations, the law allows or requires us to disclose your health information without either a written consent or authorization.

USES OR DISCLOSURES WITH CONSENT
We may ask you to sign consent form allowing us to use and disclose your health information for purposes of treatment, payment, and office operations. We are allowed to refuse to treat you if you do not sign the consent form. We use information for treatment purposes, when, for example, we set up an appointment for you, when our technician or doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when the doctor prescribes medication, when our staff helps you select and order glasses or contact lenses. And when we show you low vision aids. We may disclose your health information outside of our office for treatment purposes if, for example, we refer you to another doctor or clinic for eye care or low vision aids or services, if we send a prescription for glasses or contacts to another doctor or clinic to be filled, when we provide a prescription for medication to a pharmacist, or when we phone to let you that your glasses or contacts lenses are ready to be picked up. Sometimes we may ask for copies of your health information from another professional that you may have seen before us. We use your health information for payment purposes when, for example, our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services, when we prepare bills to send to you or your health or vision care plan, when we process payment by credit card, and when we try to collect unpaid amounts due. We may disclose your health information outside of our office for payment purposes when, for example, bills or claims for payment are mailed, faxed, or sent by computer to you or your health vision plan, or when we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due. We use and disclose your health information for office operations in a number of ways. Office operations mean those administrative and managerial functions that are necessary for running our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for defense of legal matters. To develop business plans, and for outside storage of our records.

USES AND DISCLOSURES WITHOUT CONSENT OR AUTHORIZATION
In some limited situations, the law allows or requires us to use or disclose you health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

When a state or federal law mandates that certain health information be reported for a specific purpose;

For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Food and Drug Administration regarding drugs or medical devices.

Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;

Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;

Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;

Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;

Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;

Uses or disclosures for health related research;

Uses and disclosures to prevent a serious threat to health or safety;

Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;

Disclosures relating to worker's compensation programs;

Disclosures to business associates who perform health care operations for us and who agree to keep your health information private.

APPOINTMENT REMINDERS
We may call to remind you of scheduled appointments. We may also call to notify you of other treatments or services available at our office that might help you.

OTHER DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written authorization form. You do not have to sign such a form. If you do sign one, you may revoke it at any time unless we already acted in reliance upon it.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:

Ask us to restrict our uses and disclosure for purpose of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree to this we must honor the restrictions that you want. To ask for a restriction, send us a written request to Booth Optometry Group at the address shown at the beginning of this notice.

Ask us to communicate with you in a confidential way such by phoning you at work rather than at home, by mailing health information to a different address or by using email to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us any extra cost. If you want to ask us for a confidential communications, send a written request to Booth Optometry Group at the address shown at the beginning of this notice.

Ask us to see or get photocopies of your information. By law there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us. For you may have to pay for copies in advance. If we deny your request, we will send you a written explanation and instructions of how to get partial review of our denial if one is legally required. By law we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information send a written request to Booth Optometry Group at the address shown at the beginning of this notice.

Ask us to amend your health information if you think that is incorrect or incomplete. If we agree we will amend the information within 60 days from when you ask us. We will send the corrected information to the persons whom have obtained the writing information and others that you specify. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of your position and/or your rebuttal is included in your health information, we will enclose it whenever we make a permitted disclosure of your health information. By law, we can have one 30- day extension of the time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send us a written request, including your reasons for the amendment to Booth Optometry Group at the address shown at the beginning of this notice.

Get a list of the disclosures that we have made in your health information within the past 6 years (or a shorter period if you want), except disclosures for purpose of a treatment, payment or office operations and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of the time we notify you of the extension in writing. If you want a list, send a written request to Booth Optometry Group at the address shown at the beginning of this notice.

Get additional paper copies of this Notice of Privacy Practices upon request; no matter whether you got one electronically

PROVIDING INFORMATION TO FAMILY AND FRIENDS OF PATIENTS
In order to comply with HIPAA's Privacy Rule, it is the policy of this office to give patients 18 years and older a chance to agree or object or providing protected health information to close family or friends who are helping with the patient's care.
1. If we feel that it is necessary or appropriate to inform close family member or friend who is involved in a patient's care about certain protected health information relevant to their involvement, we will do any of the following:

Get an oral agreement from the patient that the disclosure is acceptable.

Give the patient a chance to object to the disclosure.

Infer from the circumstances that the patient does not object. For example, we can reasonably infer that the patient does not object if the family member or friend is in the examining room with the patient. If the patient is not present or available when the need arises, we will use our best judgment about whether it is in the patient's best interest to disclose the information. An example might be when a family member or friend comes to our office to pick up eyewear that the patient previously ordered, as a convenience to the patient.

2. If we make a disclosure to a close family member or friend under the circumstances described in paragraph 1, we will only disclose information that is relevant to the family member or friend's involvement with the patient's care. Examples:

If the patient's spouse will pick up ordered eyewear, we will provide the eyewear but not disclose any diagnoses or special features of the eyewear.

If a son or daughter will assist a patient with eye drops, we will provide information about when and how the drops should be administered, but will not disclose the patient's diagnosis.

3. If someone is claiming to be a family member or friend of the patient initiates contact with us seeking information, we will:

Verify the identity of the caller and their relationship to the patient.

Determine if they are involved in the patient's care.

Determine if the patient is available (by phone, email, or other communication methods) to either agree or object to the disclosure. If so, we will give the patient the chance to agree or object. If the patient objects, we will not disclose any information to the caller. If the patient is not available by any reasonable means, we will use our best judgment to determine whether disclosure of information is in the patient's best interest.

OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our web site.

COMPLAINTS
If you think that we have not properly respected the privacy of your health information you are free to complain to us or the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send us a written complaint to Booth Optometry Group at the address shown at the beginning of this notice.

FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit Booth Optometry Group at the phone number or address shown at the beginning of this notice.

Financial Responsibility

Your Financial Responsibility
I understand that on the day of my service, my insurance company does not guarantee my insurance eligibility, my insurance coverage, or payment to BOOTH OPTOMETRY GROUP. I understand my insurance company states they will only determine my eligibility upon receipt of the claim. Although Booth Optometry will describe my insurance benefits, this is not a guarantee of eligibility. I UNDERSTAND AND AGREE THAT ULTIMATELY I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED BY BOOTH OPTOMETRY.

Frame Reuse Consent
I have been forewarned, although the lab uses the best professional practices to prevent such occurrences, frames may break due to the age and condition of the frame. By signing this document I am acknowledging that BOOTH OPTOMETRY GROUP and the Lab is not liable for the breakage of a previously used frame or a new frame not purchased through the office.

Notice of Privacy Practices
I have read and received the Notice of Privacy Practices. This documents explains about our privacy practice of your personal information. Your personal information will not be released to anyone unless you have authorized the release of prescription/medical record information.

Medicare Patients Signature On file
I certify that the information given by me in applying for payment under
XVII of the Social Security Act is correct.
(X) I authorize use of this form on all insurance submissions.
(X) I authorize release of information to all my insurance Companies.
(X) I authorize BOOTH OPTOMETRIST GROUP to act as my Agent in helping me obtain payment from my Insurance Companies.
(X) I authorize payment direct to BOOTH OPTOMETRIST GROUP.
(X) I permit a copy of this authorization to be used in place of the original.

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