Effective Date: 09.23.2013
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.
Revision Date: 01.29.2016
We understand that medical information about you is personal and we are committed to protecting it. We are required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this Notice of our legal duties and privacy practices with respect to your health information. We are required to follow the terms of the Notice that is currently in effect.
How We May Use or Disclose Your Health Information:
Other Uses and Disclosures of Your Health Information
- For Treatment-to dispense and provide prescription ophthalmic goods and services to you.
- For Payment-so that your vision services may be billed to and payment may be collected from you, your insurance company or a third party.
- For Health Care Operations- Certain administrative, financial, legal, and quality improvement activities necessary for us to run our business and make sure that you receive quality customer service; these activities include store operations, quality assessment/improvement activities, business planning/development, and business management and general administrative activities, including the sale, transfer, merger, or consolidation of all or part of our business with another covered entity, or an entity that following such activity will become a covered entity, and due diligence related to such activity.
- For Appointment Reminders and Health-Related Products and Services-we may use and disclose health information for annual eye examination cards, to tell you about health-related products and services, or recommend possible treatment alternatives that may be of interest to you.
- To Individuals Involved in Your Care or Payment for Your Care-we may disclose your health information to a family member or friend who is involved in your medical care or payment for your care, provided that you agree to the disclosure, or we give you an opportunity to object to the disclosure. If you are not available or are unable to agree or object, we will use our best judgment to decide whether this disclosure is in your best interests.
- As Required by Law-to comply with federal, state or local law.
- To Avert a Serious Threat to Health or Safety-we may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be only to someone able to avert the threat.
- For Public Health Activities/ Risk Prevention-for public health activities, including, for example, activities to prevent or control disease or injury; report problems with products; or, report abuse or neglect.
- For Health Oversight Activities-to a health oversight agency for activities authorized by law. These activities, which are necessary for the government to monitor the health care system, include audits, investigations, inspections and licensure.
- For Lawsuits and Disputes-if you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. In response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting that information.
- For Specialized Government Functions-(1) if you are a member of the armed forces, as required by military command authorities; (2) if you are an inmate or in lawful custody, to a correctional facility or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; (4) for national security reasons authorized by law; and (5) to authorized federal officials to protect the President, other authorized persons or head of state.
- For Workers' Compensation or other similar programs.
- Organ and Tissue Donation-to organ procurement or similar organizations for purposes of donation or transplant.
- Coroners or Funeral Directors-to a coroner or medical examiner, for example, to determine cause of death. To funeral directors consistent with applicable law to enable them to carry out their duties.
- Personal Representatives-to a person legally authorized to act on your behalf, such as a parent, legal guardian, administrator or executor of your estate, or other individual authorized under applicable law.
- Data Breach - to provide legally required notices and reports and otherwise respond to unauthorized access to or disclosure of your health information.
Except as described in this Notice, we will not use or disclose your
health information without your written authorization. If you do authorize us to use or disclose your health information, you may revoke your authorization in writing at any time. If you revoke your authorization, this will stop any further use or disclosure of your health information for purposes covered by your written authorization, except if we have already acted on your permission. Please refer to the Notice Addendum to find out about any stricter laws in your State that we must follow when using or disclosing your health information, or any State laws that give you greater rights with respect to your health information.
You Have the Following Rights with Respect to Your Health Information.
- You have the right to request that we follow special restrictions when using or disclosing your health information for treatment, payment or health care operations, or to someone who is involved in your care or the payment for your care. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your health information to a health plan for payment as discussed below. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment and other exceptions pursuant to law.
- If you paid out-of-pocket in full for a specific item or service, you have the right to ask that your health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
- With certain exceptions, you have the right to inspect and copy your health information. Usually, such information includes prescription and billing records. We may deny your request to inspect and copy in certain limited circumstances, in which case, you may request that the denial be reviewed.
- You have the right to request that we amend your health information if you feel that it is incorrect or incomplete. You must provide a reason supporting your request. We may deny your request if the health information is accurate and complete or is not part of the health information kept by or for us. Even if we deny your request for amendment, you have the right to submit a statement of disagreement regarding any item in your record you believe is incomplete or incorrect. If you request, this will become part of your medical record, and we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe is incomplete or incorrect.
- You have a right to request an accounting of disclosures of your health information. This is a list of disclosures we made of your health information, other than for treatment, payment, health care operations, and other exceptions pursuant to law. You must specify the time period, which may not be longer than six years and may not include dates before April 14, 2003.
- If your health information is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another entity. We will make every effort to provide access to your health information in the form or format you request, if it is readily so producible. If it is not so producible, your record will be provided in either our standard electronic format or a readable hard copy form, as you choose. We may charge you a reasonable, cost-based fee for that service.
- You have the right to be notified upon a breach of any of your unsecured health information.
- You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may request that we contact you only at work or at a different residence or post office box. We will accommodate all reasonable requests.
Changes to this Notice of Privacy Practices
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our store locations. If we change our Notice, you may obtain a copy of the revised Notice by visiting our website at https://www.samsclubcontacts.com/, or upon request at any of our store locations.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the Privacy Officer at (614) 921-1131. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services, Office of Civil Rights, HIPAA, 200 Independence Avenue, S.W., Washington, DC 20201. To file a complaint with us, please contact: Privacy Officer, Sam's Club Contacts, 4265 Diplomacy Dr, Columbus, OH 43228. All complaints must be submitted in writing. Forms also are available on-line at https://www.samsclubcontacts.com/ and can be submitted by E-mail to: email@example.com or by phone to (614) 921-1131. There will be no retaliation for filing a complaint.