Privacy Notice

Dr. Thomas Choponis, O.D. Notice of Privacy Practices Effective Date: 7-18-2011

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Dr. Thomas Choponis, O.D. is required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this notice of its legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all medical information we maintain. Upon request, we will provide a revised Notice to you.

How Dr. Thomas Choponis, O.D. May Use or Disclose Your Health Information Our office protects the privacy of your health information. The law permits us to use or disclose your health information for the following purposes: Treatment, Payment, and Regular Health Care Operations – Information obtained by our office will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request. As and When Required by law – We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), Judicial and Administrative, Deceased Person Information, Worker Compensations programs, Food & Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the Military or a Veteran of the armed forces when requested, or if you become an inmate in a correctional facility. Personal Communications – We may contact you to provide appointment reminders, annual eye examination cards, and other information about treatment alternatives or other health-related benefits and services that may be of interest to you as well as communicate with individuals involved in your care or payment for your care. Disclosure to Our Business Associates – There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose health information about you to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard the health information. Victims of Abuse, Neglect, or Domestic Violence – We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

Marketing Communications. We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatment, care, or alternative treatments, or providers without authorization.

When Dr. Thomas Choponis, O.D. May Not Use or Disclose Your Health Information Except as described in this Notice of Privacy Practices, Dr. Thomas Choponis, O.D. will not use or disclose your health information without your written authorization. If you do authorize Dr. Thomas Choponis, O.D. to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If your state law provides additional restrictions upon any of the foregoing uses and disclosures, we must follow your state law.

You have the following rights with respect to your health information. You have the right to request restrictions on certain uses and disclosures of your health information. To make such a request, you must complete the Restriction of the Use of Patient Information form and the request will apply only to the location providing services. Dr. Thomas Choponis, O.D. is not required to agree to the restriction that you requested. You have the right to inspect and copy your health information as long as our office maintains the health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must complete a Request to Inspect Medical Records form and submit the request to the office that provided your services. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have the right to request that Dr. Thomas Choponis, O.D. amend your health information that is incorrect or incomplete. To request an amendment, you must complete a Request to Amend Medical Records to the location providing services. Dr. Thomas Choponis, O.D. is not required to change your health information and will provide you with information about the procedure for addressing any disagreement with the denial. You have a right to receive an accounting of disclosures of your health information we have made after April 14, 2006 for most purposes other than treatment, payment, health care operations, information provided to you, and certain government functions. To request an accounting, you must complete a Request for Accounting of Disclosure to the address listed below. You must specify the time period but may not be longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time. You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of your health information, you must complete a Request for Alternative Communication to the location providing services and will be good for only the location providing services. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.

If you would like to exercise one or more of these rights, contact our office at 128 W. Spruce St. Sault Ste Marie, MI 49783 Telephone (906) 635-9600