PROTECTED HEALTH INFORMATION RIGHT TO NOTICE As a patient, you have the right to adequate notice of the uses and disclosures of protected health information (p.h.i.). Under the Health Insurance Portability and Accessibility Act (HIPPA), Dr. Broecker's office can use your p.h.i. for treatment, payment and health care operations. a). Treatment-We may use or disclose p.h.i. to a physician or other healthcare provider participating in your health care. b). Payment- We may use and disclose your p.h.i. to obtain payment for services. c). Healthcare Operations- We may use and disclose p.h.i. in connection with our health care operations. Healthcare operations include quality assessment, improvement activities, conducting training programs and licensing or credentialing. YOUR AUTHORIZATION Most uses and disclosures that don't fall under the ones noted above (see a., b., c.) will require written authorization. You may revoke your authorization at any time in writing at our practice. EMERGENCY SITUATIONS In the event of your incapacity or an emergency situation at our office, we will release health information to a family member or other person responsible for your care. Only health information pertinent to your care in that situation will be released. MARKETING We will not use your p.h.i. for marketing purposes without your written permission. REQUIRED BY LAW We may disclose health information (p.h.i.) as required by law. a). Abuse or Neglect- We may disclose p.h.i. to the appropriate authorities if we reasonably suspect you are a victim of abuse, neglect, domestic violence or other crime. We may disclose p.h.i. to the extent necessary to avert a serious threat to the safety or health or yourself or others. b). National Security- We may disclose p.h.i. of Armed Forces personnel to the military authorities under certain circumstances. We may disclose p.h.i. to Federal officials when required for lawful intelligence, counterintelligence and National Security activities. APPOINTMENT REMINDERS We may use or disclose your health information to provide you with appointment reminders via phone or postcard. RIGHTS AS A PATIENT You have the right to restrict disclosure of your p.h.i. (in writing). The request may be denied if this information is required for treatment, payment or healthcare operations. You have the right to receive communication regarding p.h.i. You have the right to inspect and copy your p.h.i. You have the right to get a copy of the disclosure history of your p.h.i. You have the right to get a paper copy of our privacy policies. LEGAL REQUIREMENTS Dr. Broecker is required by law to maintain the privacy of your p.h.i. Our office is required to abide by this notice, but we do reserve the right to make changes to it. The policies in any new notice will not be in effect until they are available in the office and are posted on our websites. COMPLAINTS A complaint may be submitted to Dr. Broecker's office if there is concern over how p.h.i. is handled. CONTACT INFORMATION Stacey T. Broecker, O.D. 2356 University Ave. #260 St. Paul, MN 55114 651-645-8124 651-645-8125 (Fax)