Hipaa Notice Of Privacy Practices Form - Delaware
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2HIPAA Notice of Privacy Practices
Delaware Eye Care Center, P.A.
333 East Main Street
833 S. Governors Avenue
110 Northeast Front Street
Dover, DE 19904
Newark, DE 19711
Milford, DE 19963
(302) 368-9105
(302) 674-1121
(302) 422-5155
10 S. Market Street
1721 Pulaski Highway
Smyrna, DE 19900
Bear, DE 19701
(302) 653-9200
(302) 836-5410
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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry
out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information. “Protected health information” is information
about you, including demographic information, that may identify you and that relates to your past, present or future physical
or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your
health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care
and any related services. This includes the coordination or management of your health care with a third party. For example,
we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For
example, your protected health information may be provided to a physician to whom you have been referred to ensure that
the physician has the necessary information to diagnose and treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For
example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to
the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the
business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities,
employee review activities, training of medical students, licensing, and conducting or arranging for other business activities.
For example, we may disclose your protected health information to medical school students that see patients at our office.
In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate
your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use
or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight:
Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral
Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation:
Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary
of the Department of Health and Human Services to investigate or determine our compliance with the requirements of
Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent. Authorization or Opportunity
to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Form: DECC003 (rev. 6/19/08)
Reorder from King Medical Systems (800) 637-3886
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