|
Purpose:
The following privacy policy is adopted to ensure that Greenwich Ophthalmology
Associates, P.C. & Fairfield County Laser Vision, LLC complies fully
with all federal and state privacy protection laws and regulations. Protection
of patient privacy is of paramount importance to this organization. Violations
of any of these provisions will result in disciplinary action including
termination of employment and possible referral for criminal prosecution.
Effective Date:
This policy is in effect as of April 15, 2003
Expiration
Date:
This policy remains in effect until superceded or cancelled.
Policy
Owner:
Greenwich Ophthalmology Associates, P.C.
Fairfield County Laser Vision, LLC;
Privacy Officer: Suresh Mandava, M.D.
Assigning
Privacy and Security Responsibilities
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that specific individuals within
our workforce are assigned the responsibility of implementing and maintaining
HIPAA Privacy Policies. Furthermore, it is the policy of Greenwich Ophthalmology
Associates, P.C. & Fairfield County Laser Vision, LLC that these individuals
will be provided sufficient resources and authority to fulfill their responsibilities.
At a minimum it is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that there will be one individual
or job description designated as the Privacy Officer.
Uses and Disclosures of Protected Health Information
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that protected health information
may not be used or disclosed except when at least one of the following
conditions is true:
- The individual who is the subject of the information (i.e. the “subject
individual”) has authorized the use or disclosure.
- The use or disclosure is for an individual’s treatment, payment
or health care operations.
- The individual who is the subject of the information does not object
to the disclosure and the disclosure is to friends or family members
involved in the health care of the individual.
- The disclosure is to the individual who is the subject of the information
or to HHS for compliance-related purposes.
- The use or disclosure is otherwise permitted or required by HIPAA.
Deceased Individuals
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that privacy protections extend
to information concerning deceased individuals.
Notice of Privacy Practices
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that a notice of privacy practices
must be provided to all patients at the earliest practicable time and
posted in our office, that any revised notice be available to patients
upon request and that all uses and disclosures of protected health information
be done in accord with this organization’s notice of privacy practices.
Restriction Requests
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that consideration must be given
to all requests for restrictions on uses and disclosures of protected
health information as stated in this organization’s notice of privacy
practices. It is furthermore the policy of this organization that if a
particular restriction is agreed to, then this organization is bound by
that restriction.
Minimum Necessary Disclosure of Protected Health Information
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that (except for disclosures
to a health care provider made for treatment purposes, disclosures to
the patient, disclosures pursuant to an authorization, or disclosures
to the Secretary of DHHS for HIPAA compliance purposes) all uses and disclosures
of protected health information must be limited to the minimum amount
of information needed to accomplish the purpose of the use or disclosure.
It is also the policy of this organization that all requests for protected
health information (except requests made for treatment purposes) must
be limited to the minimum amount of information needed to accomplish the
purpose of the request.
Access to Protected Health Information by Workforce Members
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that access to protected health
information must be granted to each employee or contractor based on the
assigned job functions of the employee or contractor only as necessary
to accomplish the assigned job function.
Access to Protected Health Information by the Subject Individual
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that, where required by state
law or HIPAA, access to protected health information must be granted to
the person who is the subject of such information within the timeframes
required by state law or the HIPAA Privacy Rule. It is the policy of Greenwich
Ophthalmology Associates, P.C.& Fairfield County Laser Vision, LLC
to inform the person requesting access of the location of protected health
information if we do not physically possess such PHI but have knowledge
of its location.
Amendment of Incomplete or Incorrect Protected Health Information
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that all requests for amendment
of protected health information maintained by this organization will be
considered in a timely fashion. If such requests demonstrate that the
information is actually incorrect or incomplete, this organization will
allow amending language to be added to the appropriate document and this
addition will be done in a timely fashion. It is not the policy of this
organization to change, remove or strike through any original document.
It is also the policy of this organization that notice of such corrections
will be given to any person or organization with which the incorrect information
has been shared who have relied or may rely on such information to the
detriment of the patient.
Access by Personal Representatives
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that access to protected health
information must be granted to personal representatives of subject individuals
as specified by subject individuals, unless there is reason to believe
that the individual has been or may be subjected to domestic violence,
abuse or neglect by the personal representative, or that treating the
person as the individual’s personal representative may endanger
the individual, and we determine that it is not in the individual’s
best interests to treat the person as the individual’s personal
representative.
Confidential Communications Channels
It is the policy of Greenwich Ophthalmology Associates, P.C.
& Fairfield County Laser Vision, LLC that confidential communications
channels be used, as requested by subject individuals, to the extent possible.
Disclosure Accounting
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that an accounting of all disclosures
of protected health information to which an individual has a right to
an receive an accounting be given to subject individuals whenever such
an accounting is requested.
Marketing Activities
It is the policy of this Greenwich Ophthalmology Associates,
P.C & Fairfield County Laser Vision, LLC that any uses or disclosures
of protected health information for marketing activities will be done
only after a valid authorization is in effect.
Complaints
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that all complaints relating to the
privacy of health information be investigated and resolved in a timely
fashion. Furthermore, it is the policy of this Greenwich Ophthalmology
Associates, P.C & Fairfield County Laser Vision, LLC that all complaints
will be addressed to Suresh Mandava, M.D. (i.e. Privacy Officer), who
will be duly authorized to investigate complaints and implement resolutions
if the complaint stems from a valid area of non compliance with the HIPAA
Privacy Rules.
Prohibited
Activities
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that no employee or contractor may
engage in any intimidating or retaliatory acts against persons who file
complaints or otherwise exercise their rights under HIPAA regulations.
It is also the policy of this organization that no employee or contractor
may condition treatment, payment, enrollment or eligibility for benefits
on the provision of an authorization to disclose protected health information,
except in specifically permitted circumstances.
Responsibility
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that the responsibility for designing
and implementing procedures to implement this policy lies with the chief
privacy officer (i.e. “CPO”).
Verification
of Identity
It is the policy of Greenwich Ophthalmology Associates, P.C & Fairfield
County Laser Vision, LLC that the identity and authority of all persons
who request access to protected health information be verified before
such access is granted as required under the HIPAA Privacy Rule.
Mitigation
It is the policy of Greenwich Ophthalmology Associates, P.C & Fairfield
County Laser Vision, LLC that the effects of any unauthorized use or disclosure
of protected health information be mitigated to the extent possible.
Safeguards
It is the policy of this Greenwich Ophthalmology Associates,
P.C & Fairfield County Laser Vision, LLC that appropriate administrative,
technical and physical safeguards will be in place to reasonably safeguard
protected health information from any intentional or unintentional use
or disclosure that is in violation of the HIPAA Privacy Rule. These safeguards
apply to information maintained in any form, including oral information,
as applicable.
Business Associates
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that business associates must be contractually
bound to protect health information to the same degree as set forth in
this policy. It is also the policy of this organization that business
associates who violate their agreement will be dealt with first by an
attempt to correct the problem, and if that fails by termination of the
agreement and discontinuation of services by the business associate and/or
notification to the Secretary of DHHS.
Training and Awareness
It is the policy of this Greenwich Ophthalmology Associates,
P.C & Fairfield County Laser Vision, LLC that all members of our workforce
have been trained by the compliance date on the policies and procedures
governing protected health information and how Greenwich Ophthalmology
Associates, P.C. & Fairfield County Laser Vision, LLC complies with
the HIPAA Privacy and Rule. It is also the policy of Greenwich Ophthalmology
Associates, P.C. & Fairfield County Laser Vision, LLC that new members
of our workforce receive training on these matters within a reasonable
time after they have joined the workforce. It is the policy of Greenwich
Ophthalmology Associates, P.C. & Fairfield County Laser Vision, LLC
to provide training should any policy or procedure related to the HIPAA
Privacy Rule materially change. This training will be provided within
a reasonable time after the policy or procedure materially changes. Furthermore,
it is the policy of Greenwich Ophthalmology Associates, P.C & Fairfield
County Laser Vision, LLC that training will be documented indicating participants,
date and subject matter.
Sanctions
It is the policy of Greenwich Ophthalmology Associates, P.C &
Fairfield County Laser Vision, LLC that sanctions will be in effect for
any member of the workforce who intentionally or unintentionally violates
any of these policies or any procedures related to the fulfillment of
these policies.
Retention of Records
It is the policy of this Greenwich Ophthalmology Associates,
P.C & Fairfield County Laser Vision, LLC that the HIPAA Privacy Rule
records retention requirement of six years will be strictly adhered to.
All records designated by HIPAA in this retention requirement will be
maintained in a manner that allows for access within a reasonable period
of time. This records retention time requirement may be extended at this
organization’s discretion to meet with other governmental regulations
or those requirements imposed by our professional liability carrier.
Cooperation
with Privacy Oversight Authorities
It is the policy of Greenwich Ophthalmology Associates, P.C & Fairfield
County Laser Vision, LLC that oversight agencies such as the Office for
Civil Rights of the Department of Health and Human Services be given full
support and cooperation in their efforts to ensure the protection of health
information within this organization. It is also the policy of this organization
to cooperate with privacy compliance reviews and investigations in accordance
with the requirements of HIPAA and other applicable law.
TOP OF PAGE
|
