About Diane L Giffen OD and Associates
We are an independent optometry practice located inside Walmart Vision Center in Kent, Ohio. The doctor does eye exams and prescribes glasses, contact lenses, and medications when indicated. Walmart Vision Center sells glasses and contact lenses.
(1.) When scheduling your appointment please provide all requested information. If you are using insurance it must be verified PRIOR to your appointment. If you do not give us enough information to verify your coverage or if your plan is one we are not a provider for, then your appointment request may be denied.
(2.) Without insurance, eye exams for glasses are $80. Exams for contact lenses range from $150 to $170 depending on what type of contact lenses you will be wearing.
(3.) We will not be examining patients who have any signs or symptoms of illness. If you are ill, please wait until you have completely recovered before scheduling your eye exam.
(4.) Only one adult patient is to be in the exam room at a time. If an adult requires assistance during the exam, then only one person may accompany the patient. For minors, only one parent may accompany the patient for the eye exam.
NOTICE OF PRIVACY PRACTICES
Diane L. Giffen, OD
250 Tallmadge Rd
Kent, Ohio 44240
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: optical staff setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you; referring you to another doctor or clinic for; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). Health care operations mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Some such uses or disclosures are:
when a state or federal law mandates that certain health information be reported for a specific purpose;
for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
disclosures for judicial and administrative proceedings, such as response to subpoenas or orders of courts;
disclosures for law enforcement purposes.
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care.
Our staff may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. Unless you tell us otherwise, we may mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want.
• ask us to communicate with you in a confidential way.
• ask to see or to get photocopies of your health information. (Copying charges may apply). By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site).
• ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension.
• get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing.
• get additional paper copies of this Notice of Privacy Practices upon request.