Morgan Vision Center’s Notice of Privacy Practices
Effective Date: May 1, 2018
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.
We understand that medical information about you is personal, and we are committed to protecting it. Morgan Vision Center, P. A. 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 our legal duties and privacy practices with respect to your health information. We are required to follow the terms of the Notice that is currently in effect.
How Morgan Vision Center May Use or Disclose Your Health Information
We may use or disclose your health information:
• For Treatment. To consult with your physician(s) or other medical personnel involved in your medical or visual care and / or to dispense and provide prescription ophthalmic goods and services to you,
• For Payment. So that your vision services may be billed to, and payment may be collected from you, your insurance company, or a third party.
• For Health Care Operations. For activities necessary to run Morgan Vision Center and make sure that you receive quality customer service.
• For Appointment Reminders and Health-Related Products and Service, Including annual eye examination cards, to tell you about health-related products and services, or recommend possible treatment alternatives that may be of interest to you.
• To Individuals Involved in Your Care or Payment for Your Care, a family member or friend who is involved in your medical care or payment for your care, provided that you
agree to the disclosure, or we give you an opportunity to object to the disclosure. If you are not available or are unable to agree or object, we will use our best judgment to decide whether this disclosure is in your best interests.
We may also disclose your health information:
• As Required by Law. To comply with federal, state or local law.
• To Avert a Serious Threat to Health or Safety. In relation to you, another person, or the public. Any disclosure would be only to someone able to avert the threat.
• For Public Health Activities/ Risk Prevention. Including activities to prevent or control disease or injury; report problems with products; or, report abuse or neglect.
• For Health Oversight Activities. When requested by a health oversight agency, where authorized by law, for activities necessary for the government to monitor the health care system, including audits, investigations, inspections and licensure.
• For Lawsuits and Disputes. In response to a court or administrative order, a subpoena, a 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 (which may include written notice to you) or to obtain an order protecting that information.
• For Specialized Government Functions. Such as, (1) if you are a member of the armed forces, as required by military command authorities; (2) if you are an inmate or in lawful custody, to a correctional facility or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; (4) for national security reasons authorized by law; and (5) to authorized federal officials to protect the President, other authorized persons or head of state.
• For Workers’ Compensation or other similar programs.
Other Uses and Disclosures of Your Health Information
Except as described in this Notice, Morgan Vision Center, P. A. will not use or disclose your health information without your written authorization. If you do authorize Morgan Vision Center to use or disclose your health information, you may revoke your authorization in writing at any time. If you revoke your authorization, this will stop any further use or disclosure of your health information for purposes covered by your written authorization, except if we have already acted on your permission.
You Have the Following Rights with Respect to Your Health Information.
• You have the right to request that we follow special restrictions when using or disclosing your health information for treatment, payment or health care operations, or to someone who is involved in your care or the payment for your care. Morgan Vision Center, P. A. is 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 and other exceptions pursuant to law.
• 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 may request that we contact you only at work or at a different residence or post office box. We will accommodate all reasonable requests. If you would like to exercise one or more of these rights, contact Morgan Vision Center, P. A. to obtain the appropriate form to complete, or submit a written request to Morgan Vision Center, P. A., 1456 Beltline Rd., Suite 129, Garland, TX 75044. A paper copy of this notice may be obtained from Morgan Vision Center upon request.
Changes to this Notice of Privacy Practices
Morgan Vision Center reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future.
For More Information or to Report a Problem
If you have questions or would like additional information about Morgan Vision Center’s privacy practices, you may contact Morgan Vision Center, P. A. at the Address above or 214-227-4342. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation, using our HIPAA Privacy Compliant Form sent to 1456 Beltline Rd., Suite 129, Garland, TX 75044, or with the Secretary of the Department Health and Human Services.
Consent for Treatment: I am presenting myself for care and treatment by D. L. Morgan, O.D. I consent to such care including diagnostic tests, including dilation of the eyes, and medical treatment by Dr. Morgan or his authorized agents as may be indicated in his professional judgment. I freely give my consent for care & treatment.
Insurance Assignment of Benefits: In the event that services rendered are to be filed with an insurance company or companies, I authorize the release of any information necessary to process insurance claims. I request that payments of benefits be paid directly to Dr. D. L. Morgan or Morgan Vision Center, P. A., for any services furnished to me by Dr. Morgan or his agents unless I have paid for all services in full. I understand that I am responsible at the time of service for paying any co-payments & deductibles. I also agree that I am responsible for payment of services rendered if I am not eligible for insurance benefits at the time for my office visit. I authorize the use of a copy of this authorization to be used in place of my signature on all my insurance submissions.
Consent for Communication: By providing my wireless number and/or email address, I understand that Morgan Vision Center, P.A. may contact me by voice, by email or by text message for the purpose of appointment reminders and product pickup notifications. I understand that I may opt-out at any time by notifying Morgan Vision Center, P.A. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.