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Policy #SOC 97-01

The University of California, Berkeley School of Optometry Clinics (UCBSO Clinics) provide comprehensive vision and eye care and are dedicated to the delivery of quality, cost effective vision care services.

Patient Rights:
  1. The patient has the right to expect appropriate health care as delivered by the UCBSO Clinics.
  2. The patient has the right to considerate and respectful care.
  3. The patient has the right to quality care regardless of his/her race, religion, education, age, sex, cultural background, physical or mental disabilities, or financial status.
  4. The patient has the right to obtain complete information concerning his/her diagnosis and treatment in terms readily understood by the patient. When there is a consultation or referral, the information will be made available to the consulting care provider.
  5. The patient has the right to know by name, the practitioner(s) responsible for coordinating his/her care.
  6. The patient has the right to be appropriately informed about his/her diagnosis prior to giving consent for referral for additional care.
  7. The patient has the right to participate in health care decisions. This includes, but is not limited to, receiving information regarding significant alternatives for care or treatment when they exist and the right to refuse treatment.
  8. The patient has the right to privacy of his/her own health care program including case discussion, consultation, examination, and treatment.
  9. The patient has the right to expect that all communications and records pertaining to his/her care will remain confidential, in accordance with State and Federal laws.
  10. The patient has the right to be informed of any experimental procedures proposed to be used in conjunction with his/her care and to refuse participation in any human experimentation without the fear that the practitioner/patient relationship will be compromised.
  11. The patient has the right to file a complaint, orally or in writing, without the fear that the practitioner/patient relationship will be compromised.
  12. The patient has the right to be informed of continuing health care requirements, if any.
Patient Responsibilities:
  1. The patient has the responsibility to provide complete and accurate information about his/her past medical history and present medical conditions including medications and other related matters.
  2. The patient has the responsibility to follow the treatment plan developed between the practitioner and the patient and to be responsible for his/her actions if he/she refuses treatment or if he/she does not follow the instructions of the practitioner.
  3. The patient has the responsibility to keep scheduled appointments or to call at least 24 hours in advance to cancel.
  4. The patient has the responsibility to conduct him/herself in an orderly, courteous, civil and cooperative manner and to modify his/her behavior upon request.
Policy #SOC 97-02

The University of California, Berkeley, School of Optometry Clinics (UCBSO Clinics) are dedicated to the delivery of quality vision care services. This includes a commitment to ensuring that inquiries and problems are resolved in a timely and equitable manner, with the opportunity for all sides to be heard and with adequate opportunities for appeal.

To ensure a well coordinated process for answering patient questions and reaching resolution for informal complaints and formal grievances regarding the provision of clinical care, the UCBSO Clinics have developed a grievance and appeals process as follows:

  1. Every attempt will be made to resolve the problem or dispute informally at the time and site of the incident with the practitioner, technician or staff person and his/her immediate supervisor. Note: For clinical issues, the supervisor is the Clinical Instructor in charge of patient care in the servicing Clinic.
  2. In the event that resolution cannot be made to the patient’s satisfaction at this level, the patient may formally bring the problem or dispute to the Clinic Director (currently the Associate Dean for Clinical Affairs) by completing a UCBSO Clinics Incident Report Form which is available at the UCBSO Clinics Registration Desk. Alternatively, a written account of the incident/problem can be directed to the Clinic Director.
  3. The final, proposed resolution will be sent to the grievant by the Clinic Director in written form, no longer than 25 working days after the receipt of UCBSO Clinics Incident Report Form or other written communication.
  4. The decision of the Clinic Director may be appealed to the Dean of the School of Optometry.
  5. The Dean may seek the advice of a Patient Advisory Committee. If the complaint involves the Clinic Director, the UCBSO Clinics Incident Report Form should be directed to the Dean at the School of Optometry. The final resolution of the grievance will be sent to the grievant by the Dean of the School of Optometry in written form no longer than 25 working days after the receipt of UCBSO Clinics Incident Report Form or other written communication.
  6. The decision of the Dean will be final within the School of Optometry of the University of California at Berkeley.
Notice of Privacy Practices

Effective date of notice: April 14, 2003

UPDATED: July 29th, 2015
Meredith W. Morgan University Eye Center
200 Minor Hall, Berkeley, CA 94720-2020
(510) 642-0945 or Fax (510) 642-2893

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

UC Optometry provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your health information is personal to you, and we are committed to protecting this information about you. As our patient, we create medical records about your health and the services and/or items we provide to you as our patient. We need this record to provide your care and to comply with certain legal requirements.

We are required by law to:

  • Protect your health information and ensure that it is kept private.
  • Provide you with a Notice of Privacy Practices and your legal rights with respect to protected health information about you.
  • Follow the conditions of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following sections describe different ways that we may use and disclose your Health Information. Some information, such as certain drug and alcohol information, HIV information, genetic information and mental health information is entitled to special restrictions related to its use and disclosure. Not every use or disclosure will be listed. All of the ways we are permitted to use and disclose information, however, will fall within one of the following categories. Other uses and disclosures not described in this Notice will be made only if we have your written authorization.

For Treatment. We may use Health Information about you to provide you with medical treatment or services. We may disclose Health Information about you to doctors, nurses, technicians, medical trainees, or other personnel who are involved in taking care of you. For example, a doctor treating you may need to know if you have diabetes because diabetes may impact your vision. A doctor treating you for glaucoma may need to know what medications you are currently taking, because the medications may affect what other medications may be prescribed to you. We may also share Health Information about you with other non- UC Berkeley School of Optometry providers. The disclosure of your Health Information to non- UC Berkeley School of Optometry providers may be done electronically through a health information exchange that allows providers involved in your care to access some of your records to coordinate services for you.

For Payment. We may use and disclose Health Information about you so that the treatment and services you receive at The Optometric Clinics of the UC Berkeley School of Optometry, may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about treatment or therapy you received at The Optometric Clinics of the UC Berkeley School of Optometry so your health plan will pay us or reimburse you for the surgery or therapy. We may also tell your health plan about a proposed treatment to determine whether your plan will pay for the treatment.

For Health Care Operations. We may use and disclose Health Information about you for our business operations. For example, your Health Information may be used to review the quality and safety of our services, or for business planning, management and administrative services. We may contact you about alternative treatment options for you or about other benefits or services we provide. We may also use and disclose your health information to an outside company that performs services for us such as accreditation, legal, computer or auditing services. These outside companies are called “business associates” and are required by law to keep your Health Information confidential. We may also disclose information to doctors, nurses, technicians, and other Optometry Clinic personnel for performance improvement and educational purposes.

Appointment Reminders. We may contact you to remind you that you have an appointment at one of our Clinics or to inform you that you have contact lenses or spectacles that are ready to be picked up.

Fundraising Activities. We may contact you to provide information about UC School of Optometry sponsored activities, including fundraising programs and events. We may use contact information, such as your name, address, and phone number, date of birth, provider name, the outcome of your care, department where you received services and the dates you received treatment or services at UC Optometry Clinics. You may opt-out of receiving fundraising information for the UC Optometry Clinics by contacting or privacy officer whose contact information can be found on the last page.

Individuals involved in Your Care or Payment For Your Care. We may release medical information to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual who you identify. We may also give information to someone who helps pay for your care.

Disaster Relief Efforts. We may disclose Health Information about you to an entity assisting in a disaster relief effort so that others can be notified about your condition, status and location.

Research. The University of California is a research institution. We may disclose Health Information about you for research purposes, subject to the confidentiality provisions of state and federal law. All research projects involving patients or the information about living patients conducted by the University of California must be approved through a special review process to protect patient safety, welfare and confidentiality. In addition to disclosing Health Information for research, researchers may contact patients regarding their interest in participating in certain research studies. Researchers may only contact you if they have been given approval to do so by the special review process. You will only become a part of one of these research projects if you agree to do so and sign a specific permission form called an Authorization. When approved through a special review process, other studies may be performed using your Health Information without requiring your authorization. These studies will not affect your treatment or welfare, and your Health Information will continue to be protected.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law or regulation.

To Prevent a Serious Threat to Health or Safety. We may use and disclose Health Information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threat.

Organ and Tissue Donation. If you are an organ donor, we may release your Health Information to organizations that obtain, bank or transplant organs, eyes or tissue, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are or were a member of the armed forces, we may release Health Information about you to military command authorities as authorized or required by law.

Workers' Compensation. We may use or disclose Health Information about you for Workers' Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.

Public Health Disclosures. We may disclose Health Information about you for public health activities such as:

  • preventing or controlling disease (such as cancer and tuberculosis), injury or disability;
  • reporting vital events such as births and deaths;
  • reporting child abuse or neglect;
  • reporting adverse events or surveillance related to food, medications.
  • notifying persons of recalls, repairs or replacements of products they may be using;
  • notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

Abuse and Neglect Reporting. We may disclose your Health Information to a government authority that is permitted by law to receive reports of abuse, neglect or domestic violence.

Health Oversight Activities. We may disclose Health Information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law.

Lawsuits and Other Legal Proceedings. We may disclose Health Information to courts, attorneys and court employees in the course of conservatorship, writs and certain other judicial or administrative proceedings. We may also disclose Health Information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, or other lawful process.

Law Enforcement. If asked to do so by law enforcement, and as authorized or required by law, we may release Health Information:

  • To identify or locate a suspect, fugitive, material witness, certain escapees, or missing person;
  • About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
  • About a death suspected to be the result of criminal conduct;
  • About criminal conduct at The Optometric Clinics of the UC Berkeley School of Optometry; and
  • In case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may also disclose medical information about patients of The Optometric Clinics of the UC Berkeley School of Optometry to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. As required by law, we may disclose Health Information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities. Protective Services for the President and Others. As required by law, we may disclose Health Information about you to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons or foreign heads of state.

Inmates. If you of a correctional institution or under the custody of law enforcement officials, we may release Health Information about you to the correctional institution as authorized or required by law.

Marketing or Sale of Health Information. Most uses and disclosures of your Health information for marketing purposes or any sale of your Health Information would require your written authorization.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

Other uses and disclosures of Health Information not covered by this Notice will be made only with your written authorization. If you authorize us to use or disclose your Health Information, you may revoke that authorization, in writing, at any time. However, the revocation will not be effective for information that we have already used and disclosed in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Your Health Information is the property of The Optometric Clinics of the UC Berkeley School of Optometry. You have the following rights regarding the Health Information we maintain about you:

Right to Inspect and Copy. With certain exceptions, you have the right to inspect and/or receive a copy of your Health Information. If we have the information in electronic format then you have the right to get your Health Information in electronic format if it is possible for us to do so. If not we will work with you to agree on a way for you to get the information electronically or as a paper copy.

To inspect, request corrections to, receive a copy of your health information, or obtain a list of disclosures you must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

If you request a copy of your health information, there is a fee for these services. We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to Health Information, in most cases, you may have the denial reviewed. Another licensed health care professional chosen by The Optometric Clinics of the UC Berkeley School of Optometry will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request an Amendment or Addendum. If you feel that Health Information we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum addition to the record). You have the right to request an amendment or addendum for as long as the information is kept by or for The Optometric Clinics of the UC Berkeley School of Optometry.

Amendment. To request an amendment, you must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

You must be specific about the information that you believe to be incorrect or incomplete and you must provide a reason that support the request. We may deny your request for an amendment if it is not in writing, we cannot determine from the request the information you are asking to be changed or corrected or your request does not include a reason to support the change or addition.

  • In addition, we may deny your request if you ask us to amend information that:
  • Was not created by The Optometric Clinics of the UC Berkeley School of Optometry
  • Is not part of the Health Information kept by or for The Optometric Clinics of the UC Berkeley School of Optometry
  • Is not part of the information which you would be permitted to inspect and copy
  • The Optometric Clinics of the UC Berkeley School of Optometry believes to be accurate and complete.

Addendum. To request an addendum must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

An addendum must not be longer than 250 words per alleged incomplete or incorrect item in your Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures we have made of your Health Information.

Accounting of Disclosures. To request this accounting of disclosures, you must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

Your request must state a time period that may not be longer than the six previous years. You are entitled to one accounting within any 12-month period at no cost. If you request a second accounting within that 12-month period, there will be a charge for the cost of compiling the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose about you for treatment, payment or health care operations.

Restrictions on Disclosure. You also have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member.

To request a restriction, you must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

In your request, you must tell us:

  • What information you want to limit.
  • Whether you want to limit our use, disclosure or both.
  • To whom you want the limits to apply, for example, only to you and your spouse.

We are not required to agree to your request except in the limited circumstance described below. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency care.

We are required to agree to a request not to share your information with your health plan if the following conditions are met:

  • We are not otherwise required by law to share the information
  • The information would be shared with your insurance company for payment purposes;
  • You pay the entire amount due for the health care item or service out of your own pocket or someone else pays the entire amount for you.

Right to Request Confidential Communications. You have the right to request that we communicate with you about your Health Information in a certain way or at a certain location. For example, you may ask that we contact you only at home or only by mail.

To request confidential medical communications you must submit your request in writing to our Privacy Officer (see contact information at the end of this document).

We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. 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. Copies of this Notice are available at our front desk, or you may obtain a copy at our website:

http://www.caleyecare.org/general-info/forms-and-policies

Right to be notified of a Breach. You have the right to be notified if we or one of our Business Associates discovers a breach of unsecured Health Information about you.

CHANGES TO THE UC BERKELEY SCHOOL OF OPTOMETRY PRIVACY PRACTICES AND THIS NOTICE

We reserve the right to change UC Berkeley School of Optometry, Eye Clinics privacy practices and 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 summary throughout the UC Berkeley School of Optometry Optometric Clinics. In addition, at any time you may request a copy of the current Notice in effect.

ELECTRONIC COMMUNICATION:

CONFIDENTIALITY NOTICE: Electronic communication is inherently insecure. The Faculty, Staff and Students of the UC Berkeley Optometric Clinics will not communicate with you electronically without your explicit written consent. Your consent does not make this communication secure or the information conveyed private. E-mail or other electronic communication including but not limited to appointment reminders, spectacle /contact lens 'ready for pick-up' notifications, spectacle / contact lens prescriptions (by request) and exam reports or evaluations are vulnerable to viewing by unauthorized third parties. Because of this the Faculty, Staff and Students of the UC Berkeley Optometric Clinics will not communicate with you electronically without your explicit written consent.

If there are any questions pertaining to the Privacy Notice, or if you feel we have not properly respected the privacy of your personal health information you may contact our Privacy Officer (see contact information at the end of this document).

QUESTIONS OR COMPLAINTS

If you have any questions about this notice, or believe your privacy rights have been violated, you may file a complaint with The Optometric Clinics of the UC Berkeley School of Optometry or with the Secretary of the Department of Health and Human Services, Office for Civil Rights. To file a written complaint with The Optometric Clinics of the UC Berkeley School of Optometry contact our Privacy Officer (see address at the end of this document).

You will not be penalized for filing a complaint.

PRIVACY OFFICER CONTACT INFORMATION:

Beth Taylor
230 Minor Hall
Berkeley, CA 94720-2020
510-642-0945

Privacy Policy (PDF): Click to Download

General Clinic Documents

Binocular Vision (BV) Forms