Policy

1.1 Privacy Notice Requirement

All patients must be given access to the Privacy Notice, which will provide information on:

• The ways in which Scottsdale Eye Physicians & Surgeons, P.C., (herewith known as Scottsdale Eye), will use and disclose the patient’s personal health information
• The patient’s rights under HIPAA
• Scottsdale Eye’s duties under HIPAA

1.2 Provision of Privacy Notice

The Privacy Notice must be provided no later than the date of the first encounter with the patient (e.g., the day of the procedure). In an emergency treatment situation, the Privacy Notice must be provided as soon as reasonably practicable after the emergency treatment situation. If the patient returns to Scottsdale Eye for another procedure, the Privacy Notice does not have to be provided again unless the Privacy Notice has been revised since the patient’s last visit. Copies must always be available and provided to patients upon request.

The Privacy Notice may be delivered electronically (e.g., by e-mail) but the patient must first agree to receive the Privacy Notice in this manner. If Scottsdale Eye receives information that the electronic Privacy Notice was not deliverable, a paper copy must be provided.

1.3 Posting of Privacy Notice

The Privacy Notice must be posted in a clear and prominent location in Scottsdale Eye (in such a place where the patient would reasonably be expected to look), e.g., the reception area. If the Privacy Notice is revised, the posted version must promptly be replaced with the new version.

If Scottsdale Eye has a web site, a copy of the Privacy Notice must be displayed on the web site. If the Privacy Notice is revised, the web site must also be updated with the revised version.

1.4 Acknowledgment of Privacy Notice

At the time the patient is provided with the Privacy Notice, Scottsdale Eye must make a good faith effort to obtain a signed or initialed acknowledgment from the patient or the patient’s personal representative. The acknowledgment is a statement that the patient has had the Privacy Notice made available to them. If a signed or initialed acknowledgment cannot be obtained, the office must document the good faith efforts that were made to obtain the acknowledgment and the reason why the acknowledgment could not be obtained. If the acknowledgment cannot be obtained because of an emergency, Scottsdale Eye must make good faith efforts to obtain the signed or initialed acknowledgment as soon as practical after the emergency situation has ended.

1.5 Revisions to Privacy Notice

The Privacy Notice must be revised if there are material changes affecting any of the following:

• Scottsdale Eye’s uses and disclosures of the patient’s information
• The individual’s rights
• Scottsdale Eye’s duties
• Any other change to Scottsdale Eye’s privacy practices

If revisions are made to the Privacy Notice because of a material change discussed above, the revised Privacy Notice must be redistributed to patients who return for another surgery or procedure. The revised Privacy Notice must also be made available and provided to patients or other persons. The revised Privacy Notice must also be posted in the reception area and, if applicable, on the web site to replace the existing Privacy Notice.

It is the policy of Scottsdale Eye that the Privacy Officer will assure that revised versions of the Privacy Notice are promptly displayed and distributed.

1.6 Retention of Privacy Notice

The Privacy Officer must keep copies of all versions of the Privacy Notice for at least six years. Signed acknowledgments and “Good Faith Effort” forms must also be kept for at least six years.

Procedure

1. The Privacy Officer will be responsible for posting the Privacy Notice in the reception area, or other location where patients will see it, as well as on Scottsdale Eye’s web site, if applicable.
2. When a patient signs in for a procedure, the reception area staff is responsible for determining whether the patient has visited Scottsdale Eye in the past and checking to see if the patient has a signed or initialed acknowledgment on file.
3. If the patient does not have a signed or initialed acknowledgment on file, employees are responsible for making a copy of the current Privacy Notice available to the patient, if requested, and obtaining a signed or initialed acknowledgment.
4. Employees will place a copy of the signed or initialed acknowledgment in the front of the patient’s chart.
5. If an employee is unable to get a signed or initialed acknowledgment, he or she is responsible for completing a “Good Faith Effort” Form and placing a copy in the front of the patient’s chart (with copy to Privacy Officer).
6. If the acknowledgment cannot be obtained because of an emergency, employees will obtain the signed acknowledgment as soon as practical after the emergency situation has ended. If the acknowledgment cannot be obtained on that date of service, a “Good Faith Effort” Form will be completed and an attempt will be made to get the acknowledgment signed on the next date of service.
7. If the Privacy Notice is revised because of a material change in Scottsdale Eye’s privacy practices, the Privacy Officer will replace the existing Privacy Notice form posted on the web site.
8. The Privacy Officer is responsible for retaining copies of the Privacy Notice and all revisions in a file for at least six years.
9. The Privacy Officer is responsible for ensuring that Scottsdale Eye retains a copy of the acknowledgment or “Good Faith Effort” forms for at least six years.

Authorities

45 CFR §164.520 (Privacy Notice)
45 CFR §164.530 (Documentation and retention)