Health Insurance Portability and Accountability Act (HIPAA) Agreement

PRIVACY POLICY

While providing our services to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information to treat you, to obtain payment for our services, and to conduct health care operations involving our office.

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as it may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes: (1) Our submission of your health information to a billing agent or vendor for processing claims or obtaining payment. (2) Our submission of claims to third-party payers or insurers for claim review, and determination of benefits and payment. (3) Our submission of your health information to auditors hired by third-party payers and insurers. (4) Other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices changes. You can receive an updated copy here at the office or from our website (drguerrieri.com)

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat and to obtain payment for our services and to perform healthcare operations.

You have the right to ask us to restrict uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions.

INSURANCE SIGNATURE ON FILE

I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I request that payment of these be made either to me or on my behalf to the office of Dr. Dennis J. Guerrieri for any services and materials furnished. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency provided and authorizes my doctor to act as my agent, as above.

I have read this document and understand it, and I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have reviewed the Notice of Privacy Practices form from the office of Dr. Dennis J. Guerrieri, OD.

If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form.



HIPAA NOTICE OF PRIVACY PRACTICES FOR PERSONAL HEALTH INFORMATION

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 carefully.

This is your Health Information Privacy Notice from the office of Dr. Dennis J. Guerrieri, OD (referred to as We or Us).

This notice is effective 05/15/2017. This notice is solely for your information. You do not need to take any action.

This notice provides you with information about the way in which We protect Personal Health Information (PHI) that We have about you. PHI includes individually identifiable information which relates to your past, present or future health,
treatment or payment for health care services. This notice also explains your rights with respect to PHI.

The Health Insurance Portability and Accountability Act (HIPAA) requires Us to: Keep Personal Health Information PHI about you private provide you this notice of our legal duties and privacy notices with respect to your PHI and follow the terms of the notice that are currently in effect.

Use and Disclosure of PHI

We obtain PHI in the course of providing and/or administering health insurance benefits for you. In administering your benefits, We may use and/or disclose Personal Health Information PHI about you and your dependents. The following are some examples, however, not every use or disclosure in a category will be listed:

  • For Health Care Payment Purposes: For example, We may use and disclose Personal Health Information PHI to administer and process payment of benefits under your insurance coverage, determine eligibility for coverage, claims or billing information, conduct utilization reviews, or to another entity or health care provider for its
    payment purposes.
  • For Health Care Operations Purposes: For example, We may use and disclose Personal Health Information PHI for underwriting and rating of the plan, audits of your claims, quality of care reviews, investigation of fraud, performance measurements, care coordination, investigate and respond to complaints or appeals, provider
    treatment, review and provision of services.
  • For Treatment Purposes: For example, We may use and disclose information PHI to health care providers to assist in their treatment of you. We do not provide health care treatment to you directly.
  • For Health Services: For example, We may use your medical information to contact you to give you information about treatment alternatives or other health related benefits and services that may be of interest to you as part of large case management or other insurance related services.
  • For Data Aggregation Purposes: For example, We may combine PHI about many insured participant to make plan benefit decisions, and the appropriate premium rate to charge.
  • To You About Dependents: For example, We may use and disclose PHI about your dependents for any purpose identified herein. We may provide an explanation of benefits for you or any of your dependents to you.
  • To Business Associates: For example, We may disclose PHI to administrators who are contracted with Us who may use the PHI to administer health insurance benefits on our behalf and such administrators may further disclose PHI to their contractors or vendors as necessary for the administration of health insurance benefits. If your state has adopted a more stringent standard regarding any of the above uses or disclosures of your PHI, those standards will be applied.

Additional Uses or Disclosures

We may also disclose PHI about you for the following purposes:

  • To comply with legal proceedings, such as a court or administrative order, subpoena or discovery requests.
  • To law enforcement officials for limited law enforcement purposes.
  • To a family member, friend or other person, for the purpose of helping you with your health care or with
    payment for your health care, if you are in a situation such as a medical emergency and you cannot give your
    agreement to the Plan to do this.
  • To your personal representatives appointed by you or designated by applicable law.
  • For research purposes in limited circumstances.
  • To a coroner, medical examiner, or funeral director about a deceased person.
  • To an organ procurement organization in limited circumstances.
  • To avert a serious threat to your health or safety or the health or safety of others.
  • To a governmental agency authorized to oversee the health care system or government programs.
  • To the Department of Health and Human Services for the investigation of compliance with HIPAA or to fulfill
    another lawful request.
  • To federal officials for lawful intelligence, counterintelligence, national security purposes and to protect the
    president.
  • To public health authorities for public health purposes.
  • To appropriate military authorities, if you are a member of the armed forces.
  • In accordance with a valid authorization signed by you.

Your Rights Regarding PHI That We Maintain About You

You have various rights as a consumer under HIPAA concerning your PHI. You may exercise any of these rights by writing to Us in care of Dr. Dennis J. Guerrieri, 231 C Street, Davis, CA, 95616.

You have the right to inspect and copy your PHI that We maintain. If you request a copy of the information, We may charge a fee for the costs of copying, mailing or other supplies associated with your request.

You have the right to ask Us to amend the PHI that is contained in a designated record set., e.g.,information used to make enrollment, eligibility, payment, claims adjudication and other decisions. You have the right to request an amendment for as long as we maintain the PHI. Requests must be made in writing and include the reason for the request. We may deny the request if the PHI is accurate and complete or if we did not create the PHI.

You have the right to request a list of our disclosures of the PHI. Your request must state a time period, may not include dates before 05/17/2017 and may not exceed a period of six years prior to the date of your request. If you request more than one list in a year, We may charge you the cost of providing the list. We will notify you of the cost and you may withdraw or modify your request before any costs are incurred. Any list of disclosures provided by Us will not include disclosures made for payment, treatment or healthcare operations made to you or persons involved in your care incidental disclosures, authorized disclosures, for national security or intelligence purposes or to correctional institutions.

You have the right to request to restrict the way We use or disclose PHI regarding treatment, payment, or health care operations. You also have the right to request to restrict the PHI We disclose about you to someone who is involved in
your care or the payment for your care. We are not required to agree to your request. If We do agree, We will comply with your request unless the information is needed to provide you emergency treatment. Your request must be in writing and state (1) what information you want to restrict (2) whether you want to restrict our use, disclosure or both and (3) to whom you want the restrictions to apply.

Uses and disclosures of your PHI, other than those listed above, require prior written authorization from you. You may
revoke that authorization at any time by writing to Us at the address at the end of this notice.

You have the right to request that We communicate personal information to you in a certain way or at a certain location. Your request must specify how or where you wish to be contacted. We will comply with reasonable requests.

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice upon request. You may request a paper copy of this notice by calling Us at (530) 758-4000, or writing to Dr. Dennis J. Guerrieri, 231 C Street, Davis, CA, 95616, Attn: HIPAA Privacy.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Us. When filing a complaint, include your name, address and telephone number and We will respond. All complaints must be submitted in writing to Dr.
Dennis J. Guerrieri, 231 C Street, Davis, CA, 95616, Attn: HIPAA Privacy.

You may also contact the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Changes To This Notice

We reserve the right to modify this Privacy Notice and our privacy policies at any time. If We make any modifications, the new terms and policies will apply to all PHI Personal Information before and after the effective date of the modifications that We maintain. If We make material changes, We will send a new notice to the insured/subscribers. If you have any questions regarding this notice, please send your written questions to the address at the end of this notice. Please include your name, the name of your insurance plan, your policy/ID number or copy of ID card, your address and telephone number and We will respond.

All questions and requests regarding your rights under this Notice should be sent to:
Dr. Dennis J. Guerrieri, 231 C Street, Davis, CA, 95616, Attn: HIPAA Privacy


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Check Coverage

Below are links to websites of some insurance providers we contract with. You may check your insurance coverage before your appointment to verify that you are eligible for services or materials.

EyeMed/Aetna (including UC Davis SHIP)

MES

Safeguard

Spectera

Superior Vision

VSP

Quick About

Dr. Guerrieri received his bachelors of science degree from the University of California, Davis in 1981 and his doctor of optometry degree from the University of Missouri, St. Louis in 1986.

Dr. Guerrieri is a member of the American Optometric Association, the California Optometric Association and the Sacramento Valley Optometric Society. He is also a member of the contact lens section of the American Optometric Association and specializes in hard to fit contact lens wearers. He lives out in the country in Davis where he and his wife, Maureen, have raised their four children.

Copyright 2018 Dr. Dennis Guerrieri. All rights reserved