RETINA CONSULTANTS OF CHARLESTON
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PERSONAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information.
For each category of uses or disclosures, we will elaborate on the meaning and provide specific
examples. Not every use or disclosure in a category will be listed. However, all of the ways we
are permitted to use and disclose information will fall within one of the categories.
• For Payment. We may use and disclose medical information about you so that the
treatment and services you receive at the Practice may be billed to and payment may be
collected from you, an insurance company or a third party. For example, it may be
essential that you provide us with your health plan information regarding care you
receive at the Practice so that your health plan will pay us or reimburse you for those
services. In addition, we may tell your health plan about a treatment you are going to
receive in order to obtain necessary approval or to determine whether your plan will
cover the treatment. You may restrict the disclosure of your PHI to a health plan if the
disclosure is for payment or health care operations and pertains to a health care item or
service for which you have paid out of pocket in full.
• For Treatment. We may use medical information about you to provide you with medical
treatment or services. We may disclose medical information about you to doctors, nurses,
tecghnicians, medical students, or other Practice personnel who are involved in taking care
of you at the Practice. For example, a doctor treating you for a broken leg may need to
know if you have diabetes so that he/she can arrange for an appropriate diet. Different
departments of the Practice also may share medical information about you in order to
coordinate the different services you need, such as prescriptions, lab work and x-rays. We
, also may disclose medical information about you to people outside the Practice who may
be involved in your medical care after you leave the Practice, such as family members,
clergy or other persons that are part of your care.
• For Health Care Operations. We may use and disclose medical information about you
for Practice operations. These uses and disclosures are necessary to run the Practice and
ensure that all of our patients receive quality care. For example, we may combine medical
information about a variety of Practice patients to decide what additional services the
practice should offer, what services are not needed, and whether certain new treatments
are effective. We may also disclose information to doctors, nurses, technicians, medical
students, and other Practice personnel for review and learning purposes. We may
combine the medical information we have along with medical information from other
practices to compare how we are doing and thus, evaluate where we can make
improvements in the care and services we provide. We may remove information that
identifies you from this set of medical information so that others may use it to study
health care and health care delivery, without learning the identity of the patients.
WHO WILL FOLLOW THIS NOTICE.
This notice describes our organization’s practices and that of:
• Any health care professional authorized to enter information into your chart.
• All departments and units o fthe Practice.
• All employees, staff and other Practice personnel.
• All of these entities, sites and locations follow the terms ofthis notice. In addition, these
entities, sites and locations may share medical information with each other for treatment,
payment or Practice operations purposes described in this notice.
POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION.
We understand that medical information pertaining to you and your health is personal. We are
committed to protecting your medical information. We create a record of the care and services
you receive at the Practice. We need this record in order to provide you with quality care and to
comply with certain legal requirements. This notice applies to all of the records of your care
generated by the Practice, whether made by Practice personnel or by your personal doctor. Your
personal doctor may have different policies or notices regarding the doctor’s use and disclosure
of your medical information created in the doctor’s office or clinic.
This notice will inform you about the different ways in which we may use and disclose medical
information about you. We also describe your rights and certain obligations we have regarding
the use and disclosure of medical information.
The law requires us to:
• Make sure that medical information that identifies you is kept private;
• Acquire your authorization before any use or disclosure of any psychotherapy notes, PHI
for marketing purposes, and sales ofPHI;
• Give you this notice of our legal duties and privacy practices with respect to medical
information about you; and
• Follow the terms of the notice that is currently in effect.

OTHER CATEGORIES OF INFORMATION THAT WE MAY USE OR DISCLOSE
INCLUDE.
Appointment Reminders. We may use and disclose medical information to contact you as a
reminder that you have an appointment for treatment or medical care at the Practice.
As Required By Law. We will disclose medical information about you when required to do so
by federal, state or local law.
Health-Related Benefits and Services. We may use and disclose medical information to tell
you about health-related benefits or services that may be of interests to you.
Individual Involved in Your Care or Payment for Your Care. We may release medical
information about you to a friend or family member who is involved in your medical care. We
may also give information to someone who helps pay for your care. We may also inform your
family or friends about your condition. In addition, we may disclose medical information about
you to an entity assisting in a disaster relief effort so that your family can be notified about your
condition, status and location.
Research. Under certain circumstances, we may use and disclose medical information about you
for research purposes. For example, a research project may involve comparing the health and
recovery of all patients who received another treatment, for the same condition. All research
projects, however, are subject to a special approval process. This process evaluates a
proposed research project and its use of medical information in order to balance the research
needs with patients’ need for privacy of their medial information. Before we use or disclose
medical information for research, the project will have been approved through this research
approval process, but we may, however, disclose medical information about you to people
preparing to conduct a research project, for example, to help them look for patients with specific
medical needs, as long as the medical information they review does not leave the Practice. We
will almost always ask for your specific permission ifthe researcher obtains access to your name,
address or other information that reveals who you are, or will be involved in your care at the
Practice.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information
about you when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would only be to someone able
to help prevent the threat.
Treatment Alternatives. We may use and disclose medical information to inform you about,
recommend possible treatment options or alternatives that may be of interest to you.
LESS FREQUENT USES AND DISCLOSURES OF YOUR PERSONAL INFORMATION
INVOLVING THOSE NOT DIRECTLY INVOLVED IN YOUR CARE COULD INCLUDE:
• Coroners, Medical Examiners and Funeral Directors. We may release medical
information to a coroner or medical examiner, in order to identify a deceased person or
determine the cause of death. We may also release medical information about patients of
the Practice to funeral directors as necessary to carry out their services.
• Health Oversight Activities. We may disclose medical information to a health oversight
agency for activities authorized by law. These oversight activities include, for example,
audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, and compliance
with civil rights laws.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release medical information about you to the correctional
institution or law enforcement official. This release would be necessary: (1) for the
institution to provide you with health care; (2) to protect your health and safety or the
health and safety of others; or (3) for the safety and security of the correctional
institution.
• Law Enforcement. We may release medical information if asked to do so by a law
enforcement official: –
o In response to a court order, subpoena, warrant, summons or similar process;
o To identify or locate a suspect, fugitive, material witness, or missing person;
o About the victim of a crime if, under certain limited circumstances, we are unable
to obtain the person’s agreement;
o About a death we believe may be the result of criminal conduct;
o About criminal conduct at the Practice; and
o In emergency circumstances to report a crime; the location of the crime or victims;
or to identify, description or location of the person who committed the crime.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose
medical information about you in response to a court or administrative order. We may
also disclose medical information about you in response to a subpoena, discovery request,
or other lawful process by someone else involved in the dispute, but only if efforts have
been made to tell you about the request or to obtain an order protecting the information
requested.
• Military and Veterans. If you are a member -of the armed forces, we may release
medical information about you as required by military command authorities. We may
also release medical information about foreign military personnel to the appropriate
foreign military authority.
• National Security and Intelligence Activities. We may release medical information
about you to authorized federal officials for intelligence, counterintelligence, and other
national security activities authorized by law.
• Organ and Tissue Donation. If you are an organ donor, we may release medical
information to organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue
donation and transplantation.
• Protective Services for the President and Others. We may disclose medical
information about you to authorized federal officials so they may provide protection to
the President, other authorized persons, and foreign heads of state or conduct special
investigations.
• Public Health Risks. We may disclose medical information about you for public health
activities. These activities generally include the following, but are not limited to:
o Preventing or controlling disease, injury or disability;
o Reporting births and deaths;
o Reporting child abuse or neglect;
o Reporting reactions to medications or problems with products;
o Notifying people of recalls of products they may be using;
o Notifying a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition;
o Notifying the appropriate government authority if we believe a patient has been a
victim of abuse, neglect or domestic violence. We will only make this disclosure if
you agree or when required or authorized by law.
• Worker’s Compensation. We may release medical information about you for worker’s
compensation or similar programs. These programs provide benefits for work-related
injuries or illness.
Uses and disclosures not described in this Notice ofPrivacy Practices will be made only with
your authorization.
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you:
• Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures.” This is a list ofthe disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the
Practice’s Privacy Officer. Your request must state a time period, which may not be longer than
six years and may not include dates before February 26, 2003. Your request should indicate in
what form you want the list (for example, on paper, electronically). The first list you request
within a 12-month period will be free. For additional lists, we may charge you for the cost of
providing the list. We will notify you of the cost involved and you may choose to withdraw or
modify your request at that time before any costs are incurred.
• Right to Amend. If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for the Practice. To request an
amendment, your request must be made in writing and submitted to the Practice’s Privacy
Officer. In addition, you must provide a reason that supports your request. .
o We may deny your request for an amendment if it is not “in writing or does not include a
reason to support the request. In addition, we may deny your request if you ask us to
amend information that:
o Was not created by us, unless the person or entity that created the information is no longer
available to make the amendment;
o Is not part of the medical information kept by or for the Practice;
o Is not part of information which you would be permitted to inspect and copy; or
o Is accurate and complete.
• Right to Inspect and Copy. You have the right to inspect and copy medical information that
may be used to make decisions about your care. You may access PHI maintained electronically in
one or more designated record sets, whether or not the designated record set is an electronic
health record. Usually, this includes medical and billing records, but does not include
psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, you
must submit your request in writing to the Practice’s Privacy Officer. If you request a copy of the
information, we are entitled to charge a reasonable fee for the costs of copying, mailing or other
supplies associated with your request, whether it is in paper or electronic form.
If you request an electronic copy of PHI that is maintained electronically in one or more
designated record sets, we will provide you with access to the electronic information in the
electronic form and format that you requested, if it is readily producible, or if not, in a readable
electronic form and format as agreed.
If so requested, we will transmit the requested copy ofPHI directly to a designated person, if your
request is: (1) in writing; (2) signed by you; and (3) clearly identifies the designated person and
where we should send the PHI.
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We will respond to your request within 30 days. If the information cannot be gathered within the
initial 30-day period, then we will respond with a written notice of the reasons for the delay and
the expected date, no later than 60-days from the original request. However, we may deny your
request to inspect and copy in certain very limited circumstances. If you are denied access to
medical information, you may request that the denial be reviewed. Another licensed health care
professional chosen by the Practice will review your request and the denial. The person
conducting the review will not be the person who denied your request. We will comply with the
outcome of the review.
• Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You
may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy
of this notice contact the Practice’s Privacy Officer.
• Right to Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing in the Practice’s
Privacy Officer. We will not ask you the reason for the request and will accommodate all
reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to Restrict Disclosures to Health Plan. You have the right to restrict disclosures of PHI
to a health plan if the disclosure is for payment or health care operations and pertains to a health
care item or service for which you have paid out of pocket in full.
• Right to be Notified of Breach. You have the right to or you will be notified following a breach
of unsecured PHI if you are affected by the breach.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the
medical information we use or disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the medical information we disclose
about you to someone who is involved in your care or the payment for your care, like a family
member or friend. For example, you could ask that we not use or disclose information about a
surgery you had. We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Privacy Officer. In your request,
you must tell us (1) what information you want to limit; (2) whether you want to limit our use,
disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your
spouse.
We will honor your request to restrict disclosure of your PHI to a health plan if (1) the disclosure
is for the purpose of carrying out payment or health care operations and is not otherwise required
by law and (2) the PHI pertains solely to a health care item or service for which you, or a person
other the health plan on your behalf (such as a family member), has paid the covered entity for in
full.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice
effective for medical information we already have about you as well as any information we receive in the
future. We will post a copy of the current notice in the Practice. The notice will contain on the first page,
in the top right-hand comer, the effective date. In addition, each time you visit the Practice for treatment
or health care services, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Practice or with
the Secretary of the Department of Health and Human Services. To file a complaint with the Practice,
contact Privacy Officer, (843) 763-4466,3531 Mary Ader Ave., Charleston, SC29414.. This should be the same
person or department listed on the first page as the contact for more information about this notice. All
complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to use
will be made only with your written permission. If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about you for the reasons covered by
your written authorization. You understand that we are unable to take back any disclosures we have
already made with your permission, and that we are required to retain our records of the care that we
provide to you.
If you have any questions about this notice, please contact the Practice Privacy Officer.