of Privacy Practices
Effective date of notice: Feb. 1, 2008
Of Optometry - Grant A. Nakajima, O.D.
4 Harris Court, Suite B
Monterey, California 93940
This notice describes how medical
information about you may be used and disclosed, and how you can obtain access to
this information. Please review it carefully.
We respect our legal
obligation to keep health information, that identifies you, private. The law
obligates us to give you notice of our privacy practices.
Generally, we can only use your health information in our
office or disclose it outside of our office, without your written permission,
for purposes of treatment, payment or healthcare operations. In most other
situations, we will not use or disclose your health information unless you sign
a written authorization form. In some limited situations, the law allows or
requires us to disclose your health information without written authorization.
Uses or Disclosures of Health Information
Examples of how we use information for treatment purposes:
- When we set up an appointment for you.
- When our technician or doctor tests
- When the doctor prescribes glasses or
- When the doctor prescribes medication.
- When our staff helps you select and
order glasses or contact lenses.
- When we show you low vision aids.
We may disclose your health information outside of our
office for treatment purposes, for
- If 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 professional to be filled.
- When we provide a prescription for
medication to a pharmacist.
- When we phone to let you know that your
glasses or contact 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.
We may use your health information within our office or disclose your health information
outside of our office for payment purposes. Some examples are:
- When our staff asks you about health or
vision care plans that you may belong to, or about other sources of payment for
- 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.
- When bills or claims for payment are
mailed, faxed, or sent by computer to you or your health or vision plan.
- 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 healthcare operations in a number of
ways. Health care operations means those administrative and managerial
functions that we have to do in order to run 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 the defense of legal matters, to develop
business plans, and for outside storage of our records.
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.
Uses & Disclosures without an Authorization
In some limited
situations, the law allows or requires us to use or disclose your health
information without your permission. Not all of these situations will apply to
us; some may never happen at our office at all. Such uses or disclosures are:
- A state or federal law that mandates
certain health information be reported for a specific purpose.
- 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, audits by Medicare
or Medicaid, or investigation of possible violations of healthcare 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
- 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
- Disclosures relating to workers' compensation programs.
- Disclosures to business associates who
perform healthcare operations for us and who agree to keep your health
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 have already acted in
reliance upon it.
Your Rights Regarding Your Health Information
law gives you many rights regarding your health information.
- You can ask us to restrict our uses and
disclosures for purposes of treatment (except emergency treatment), payment or
healthcare operations. We do not have to agree to do this, but if we agree, we
must honor the restrictions that you want. To ask for a restriction, send a
written request to Grant Nakajima, Privacy Officer at the address, fax or
e-mail shown at the beginning of this notice.
- You can ask us to communicate with you
in a confidential way, such as by phoning you at work rather than at home, by
mailing health information to a different address, or by using e-mail to your
personal email address. We will accommodate these requests if they are reasonable,
and if you pay us for any extra cost. If you want to ask for confidential
communications, send a written request to Grant Nakajima, Privacy Officer at
the address, fax or e-mail shown at the beginning of this notice.
- You can ask to see or to get
photocopies of your health information. By law, there are a few limited
situations in which we can refuse to permit access or copying. Primarily,
however, you will be able to review or have a copy of your health information
within 30 days of asking us. You may have to pay for photocopies in advance. If
we deny your request, we will send you a written explanation, and instructions
about how to get an impartial 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 sent you a written notice of the extension. If you want to
review or get photocopies of your health information, send a written request to
Grant Nakajima, Privacy Officer at the address, fax or e-mail shown at the
beginning of this notice.
- You can ask us to amend your health
information if you think that it 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 persons who we know got the wrong 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 position and/or
rebuttal is included in your health information, we will send it along whenever
we make a permitted disclosure of your health information. By law, we can have
one 30-day extension of 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 a written request, including your reasons for the amendment,
to Grant Nakajima, Privacy Officer at the address, fax or e-mail shown at the
beginning of this notice.
- You can get a list of the disclosures
that we have made of your health information within the past six years (or a
shorter period if you want), except disclosures for purposes of treatment,
payment or health care operations, disclosures made in accordance with an
authorization signed by you, 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 time if we notify you of the extension in writing. If you want a
list, send a written request to Grant Nakajima, Privacy Officer at the address,
fax or e-mail shown at the beginning of this notice.
Our Notice of Privacy Practices
By law, we must abide by the terms of this Notice of Privacy
Practices until we choose to change it. We reserve the right 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 your 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
If you think that we have not properly respected the privacy
of your health information, you are free to complain to us or to the U.S.
Department of Health and Human Services, Office for Civil Rights. We will not
retaliate against you if you make a complaint. If you want to complain to us,
send a written complaint to Grant Nakajima, Privacy Officer at the address, fax
or e-mail shown at the beginning of this notice. If you prefer, you can discuss
your complaint in person or by phone.
For More Information
If you want more information about our privacy practices,
call or visit Grant Nakajima, Privacy Officer at the address or phone number
shown at the beginning of this notice.