Privacy Officer: Randall Keeton         Effective Date: April 1, 2003


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 caefully.


We care about our patients' privacy and strive to protect the confidentiality of your medical information at this practice.  Federal legislation requires that we issue this official notice of our privacy practices.  You have the right to the confidentiality of your medical information, and this practice is required by law to maintain the privacy of that protected health information.  This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information.  If you have any questions about this Notice, please contact the Privacy Officer at this practice.



Who will follow this notice

Any health care professional authorized to enter information to your medical record, all employee, staff and other personnel at this practice who may need access to your information must abide by this Notice.  All subsidiaries, business associates, sites and location of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice.  Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.


How we may use and disclose medical information about you


The following categories describe different ways that we may use and disclose medical information without your specific consent or authorization.  Examples are provided for each category of uses or disclosures.  Not every possible use or disclosure in a category is listed.


For treatment.  We may use medical information about you to provide you with medical treatment or services.  Example:  In treating you for a specific condition, we may need to know if you have allergies that could influence which medications we prescribe for the treatment process.


For payment.  We may use and disclose medical information about you so that the treatment and services you receive from us can be billed and payment may be collected from you, an insurance company or a third parte.  Example:  We may need to send your protected health information, name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.


For health care operations.  We may use and disclose medical information about you for health care operations to assure that you receive quality care.  Example:  We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.


Other uses or disclosures that can be made without consent or authorization

*  As required during an investigation by law inforcement agencies

*  To avert a serious threat to public health or safety

*  As required by military command authorities for their medical records

*  To workers' compensation or similar programs for processing of claims

*  In response to legal proceeding

*  To a coroner or medical examiner for identification of a body

*  If an inmate, to the correctional institution or law enforcement official

*  As required by the US Food and Drug Administration(FDA)


We may contact you to provide appointment reminders or information about your treatment alternatives or other health-related benefits and services that may be of interest to you.


Uses and disclosures of protected health information requiring your written authorization

Other uses and disclosures of medical information not covered by the Notice or the laws that apply to us will be made only with written authorization.  If you give us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back and disclosures that we made with your permission and that we are required to retain our records of the care we have provided you.


Your individual rights regarding your medical information


Complaints:  If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of Department of Health and Human Services.  All complaints must be submitted in writing.  You will not be penalized or discriminated against for filing a complaint.


Right to request restrictions:  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or in the payment of your care.  We are not required to agree to your request.  If we do agree, we will comply to your request unless the information is needed to provide you with emergency treatment.  To request restrictions, you must submit your request in writing to the Privacy Officer at this practice.  In your request, you must tell us what information you want us to limit and where in your records this information is contained.


Right to request confidential communications:  You have the right to request how we should send communications to you about medical matters and where you would like those communications sent.  To request confidential communications, you must make your request in writing to the Privacy Officer at this practice.  We will not ask you the reason for your request.  We will accommodate all reasonable requests, but reserve the right to charge you a cost-based fee for any non-customary expenses involved.  Your request must specify how or where you wish to be contacted.


Right to inspect and copy:  You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually this includes medical and billing records but does not include psychotherapy notes, information for use in a civil, criminal, or administrative action or proceeding and protected health information to which access is prohibited by law.  To inspect and copy medical information that may be used to make decisions about you, you must submit a request in writing to the Privacy Officer at this practice.  If you request a copy of the information, we reserve the right to charge a fee for the cost of copying, mailing or other supplies associated with your request.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, your may request that the denial be reviewed.  Another licensed health care professional chosen by this practice will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comly with the outcome of the review.


Right to amend:  If you feel that medical information that we have about you is incorrect or imcomplete, you may ask us to amend the information.  You have the right to ask for an amendment for as long as the information is kept.  To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice.  In addition, you must provide a reason that supports your request.  We may deny your request for an amendment if it is not in writing or does not support a reason for the request.  In addition, we may deny your request if the information was not created by us, is not a part of the medical information kept at this practice, is not a part of the information you would be permitted to inspect and copy or which we deem to be accurate or complete.  If we deny your request for amendment, you have the right to file a statement of disagreement with us.  We may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.  Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized request for information pertaining to the appropriate portion of your record.


Right to an accounting of non-standard disclosures:  You have the right to request a list of the disclosures of medical information we make about you.  To request this list you must make your request in writing to the Privacy Officer at this practice.  Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years, and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (example: on paper or electronically).  The first list you request in a twelve month period will be free.  For additional lists, we reserve the right to charge you for the cost of providing the list.


Right to a paper copy of this notice:  You have the right to a paper copy of our current Notice of Privacy Practices at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to receive a paper copy.  To obtain a paper copy of the current Notice, Please request one in writing from the Privacy Officer at this practice.  You may also print this Notice from our website: Keetonvisioncare.com. 


Keeton Vision Care
5901 Mexico Rd
Saint PetersMissouri 63376


Phone:  636 498-2020 636 498-2020

Fax:  636 498-0500




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