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Gilbert Eyecare Patient Forms

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

DISCLOSURE OF YOUR HEALTHCARE INFORMATION

This medical practice collects health information regarding you and stores that information in an electronic health record/personal health record. These records are the property of our medical practice but the information in these records belongs to you. The law permits us to use or disclose your health information for the following purposes:

Treatment:

We may disclose your healthcare information to other healthcare professionals, pharmacies, laboratories, employees and business associates who are involved in providing the care you need. We may also disclose to immediate family members including spouse, parents, adult children, guardians, and insurance companies for the purpose of treatment, payment, or healthcare operations.

Payment:

We may disclose your health information to your insurance provider for the purpose of payment or healthcare operations.

Health Care Operations:

We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Appointment Reminders:

We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

Sign In Sheet:

We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

Notification and Communication With Family:

We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

Marketing:

Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

Fundraising:

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

Workers’ Compensation:

We may disclose your health information as necessary to comply with Virginia State Worker’s Compensation Laws.

Public Health and Oversight Activities:

As required by law, we may disclose your health information to public health authorities and oversight agencies for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure, and in the course of audits, investigations, inspections licensure and other proceedings, subject to the limitations imposed by the law.

Judicial And Administrative Proceedings:

We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement:

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

Deceased Persons:

We may disclose your health information to coroners or medical examiners.

Organ Donation:

We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

Research:

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety:

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

Specialized Government Agencies:

We may disclose your health information for military, national security, prisoner and government benefits purposes.

Change of Ownership:

In the event that Dr. David Gilbert & Associates Optometrist, P.C. is sold or merged with another organization, your health information/ record will become the property of the new owner.

Breach Notification:

In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.

When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Your Health Information Rights

  • You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.
  • You have the right to have your health information received or communicated in through an alternative location other than the usual method of communication or delivery upon your request.
  • You have the right to inspect and copy health information.
  • You have the right to request that Dr. David Gilbert & Associates Optometrist, P.C. amend your protected health information. Please be advised, however, that Dr. David Gilbert & Associates Optometrist, P.C. is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
  • You have the right to receive an accounting of disclosures of your protected health information made by Dr. David Gilbert & Associates Optometrist, P.C.
  • You have the right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

Dr. David Gilbert & Associates Optometrist, P.C. reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make all new provisions effective for all information that it maintains. Until such amendment is made, Dr. David Gilbert & Associates Optometrist, P.C. is required by law to comply with this notice.

Dr. David Gilbert & Associates Optometrist, P.C. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have any questions about any part of this notice, or if you want more information about your privacy rights, please contact Dr. David Gilbert by calling (757)425-0200. If Dr. David Gilbert is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days (Mon. – Thurs.)

Complaints

Complaints about your privacy rights or how Dr. David Gilbert & Associates Optometrist, P.C. has handled your health information should be directed to Dr. David Gilbert by calling the office at (757)425-0200. If Dr. David Gilbert is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days (Mon. – Thurs.)

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Ave., S.W.
Room 509F HHH Building
Washington, DC 20201
Email: OCRMail@hhs.gov
Complaint Form: www.hhs.gov/ocr/rivacy/hipaa/complaints.pdf

Virginia Beach Location

Our Virginia Beach Eye Care office is conveniently located off Laskin Road in Hilltop.

1547 Laskin Road
Virginia Beach, VA 23451

757-425-0200

customerservice@gilberteyecare.com

Norfolk Location

Our Norfolk Eye Care office is off Brambleton Avenue in downtown Norfolk.

220 W. Brambleton Avenue
Norfolk, VA 23510

757-622-0200

customerservice@gilberteyecare.com

5 Star Google Reviews

I love this practice!

Everyone in this office is super friendly and informative, and I don't feel as if I am just there to be a dollar sign to the practice. They really have your interest and health in mind and it shows in how they run their appointments and the care and explanation you get. Continue Reading

- Deidra

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