Notice of Privacy Practices

Patient Authorization Form




This Notice describes the Information Privacy Practices followed by Massachusetts Eye and Ear Infirmary, and Massachusetts Eye and Ear Associates, Inc., and their medical staff, physicians, nurses and other personnel (collectively “Mass. Eye and Ear” or “we”). Massachusetts Eye and Ear Infirmary, and Massachusetts Eye and Ear Associates, Inc., operate as an affiliated covered entity and as an organized health care arrangement under federal law. This Notice applies to our services provided at the Massachusetts Eye and Ear Infirmary located at 243 Charles Street, Boston, Massachusetts, and at other clinical sites owned or operated by Mass. Eye and Ear.

Mass. Eye and Ear is required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information. The Notice also describes your rights with respect to your protected health information. “Protected health information”, or “PHI”, is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health condition, and related health care services.

Mass. Eye and Ear is required to follow the terms of this Notice of Privacy Practices. We will not use or disclose your protected health information without your written permission, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all protected health information we maintain. The Notice in effect at any given time will be posted on our web site,, and in waiting areas around Mass. Eye and Ear and at our affiliated clinical sites. Upon your request, we will provide you with a revised Notice.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU The following categories describe different ways that we use and disclose your protected health information (PHI). For each category of uses or disclosures, we provide some examples.

Use and Disclosure of your PHI Without Your Authorization
Information obtained by a nurse, physician, or other member of your health care team will be recorded in your health record and used to determine and implement your course of treatment. Your health record will include the information necessary for us to provide your care. Mass. Eye and Ear staff may share information about you and disclose information to people outside of Mass. Eye and Ear in order to coordinate or manage your care, such as phoning in prescriptions to your pharmacy, scheduling lab work, ordering imaging services, or coordinating with another physician or entity that also provides you health care.

Payment: A bill may be sent to you, or a third-party payor, for care that you receive from Mass. Eye and Ear. The information on or accompanying the bill may include information that identifies you, as well as, your diagnosis, procedures, and supplies used.

Health Care Operations: Mass. Eye and Ear may use information about you to operate our facilities and carry out our mission. For example, we may use your information to assess the care and outcomes in your case and others like it. We may also disclose your PHI for certain limited health care operations of other health care providers.

Disclosures to Other Health Care Providers: Mass. Eye and Ear may enter into organized health care arrangements with other health care providers for the collaborative delivery of care. In such cases, Mass. Eye and Ear will use and disclose PHI with the other members of the organized health care arrangements for purposes of treatment, payment and health care operations, or as otherwise permitted by this Notice.

Business Associates: There are some services provided to Mass. Eye and Ear through contracts with business associates. Examples of services that may be provided by business associates include billing, information technology, legal services, or publicity. When we contract for these services, we may disclose your PHI to our business associates so that they can perform the job we have asked them to do for us. To protect your information, however, business associates must also have safeguards in place to keep your PHI private.

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

Fundraising: We may contact you to request a tax-deductible contribution to support the important activities of Mass. Eye and Ear. However, you have a right to opt out of Mass. Eye and Ear fundraising communications. We will not prohibit or condition treatment or payment on whether you choose to receive fundraising communications. If you wish to make a tax-deductible contribution or do not want to receive any fundraising requests in the future, you may contact the Mass. Eye and Ear Development Office at 617-573-3345.

Food and Drug Administration (FDA): We may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to food, medicines, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability, and/or charged with collecting data on births and deaths.

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

To Avert a Serious Threat to Health or Safety: We may use and disclose your PHI when necessary to prevent or lessen a serious threat to your health and safety, or the health and safety of the public or another person.

Victims of Abuse, Neglect or Domestic Violence: We may disclose PHI about you to a government authority, such as the Massachusetts Office for Children or the Massachusetts Executive Office of Elder Affairs, if we reasonably believe you are a victim of abuse or neglect. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is required or allowed by law and we believe it is necessary to prevent serious harm to you or someone else, or the law enforcement or public official that is to receive the report demonstrates that it is necessary and will not be used against you. In such cases, we will promptly inform you that a report has been, or will be, made unless there is reason to believe that providing this information will place you or another person in serious harm.

Law Enforcement and Legal Compliance: We will disclose your PHI for law enforcement purposes as required by law or in response to a valid subpoena or court order. We will disclose your PHI when required to do so by federal, state, or local law. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. Subject to applicable state law, we may also disclose PHI about you 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, either by us, or the requesting party, to tell you about the request or to obtain an order protecting the information requested.

Regulatory Compliance: Federal law allows your PHI to be released to an appropriate health oversight agency, public health authority or attorney, if a member of our work force, or business associate, believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards, and are potentially endangering one or more patients, workers or the public.

Research: We may disclose your PHI to researchers when their research protocols and privacy measures have been reviewed and approved by an institutional review board. In addition, certain elements of your PHI may be reviewed by our clinicians, employees or workforce to determine your potential eligibility for one or more clinical research trials, and we may contact you to determine your willingness to participate.

Organ or Tissue Procurement Organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Worker’s Compensation: We may disclose your PHI to the extent authorized by law and as necessary to comply with laws relating to worker’s compensation.

Military and Veterans: If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Correctional Institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health, and the health and safety of other individuals.

National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations.

Use and Disclosure of your PHI When You Have the Opportunity to Object
Directory (Inpatient only):
If you are admitted as an inpatient, we e may include your name, location, general condition, and religious affiliation in an inpatient directory without obtaining your written consent or authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name, or by members of the clergy; but your religious affiliation will only be disclosed to members of the clergy.

Communication with Individuals Involved in Your Care or Payment for Your Care: Unless you object, health professionals, such as a physician or a nurse, using their professional judgment, may disclose to a family member, close personal friend, personal representative or any other person you identify, PHI relevant to that person’s involvement in your care, or payment related to your care or who may need to notify others about your location, general condition or death.

Disaster Relief: We may use or disclose your PHI to an entity, authorized by its charter or by law, to assist in a disaster relief effort (such as the American Red Cross) for the purpose of coordinating with such entities to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.

Use and Disclosure of your PHI Requiring Your Authorization:
We will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for above (or as otherwise permitted or required by law). We are required to obtain your written authorization for most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes, including subsidized treatment communications, disclosures that constitute a sale of PHI, and other uses and disclosures not described in this Notice. You may revoke an authorization in writing at any time. Upon receipt of a written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Additional Protection of Your Health Information:
Special state and federal laws apply to certain classes of patient health information. For example, additional protections may apply to information about sexually transmitted diseases, drug and alcohol abuse treatment records, mental health records, and HIV/AIDS information. When required by law, we will obtain your authorization before releasing this type of information.

You have the following rights with respect to your protected health information:

Request a Restriction on Certain Uses and Disclosures of Your Information: You have the right to request that we not use or disclose your PHI for a particular purpose related to treatment, payment, or health care operations, and/or that we limit the information that we disclose to a particular family member, other relative or close personal friend, or any other person involved in your care or payment for your care. For example, you may request that we not notify a family member of your location or general condition, or you may request that we not use or disclose information about a medical procedure that you had. However, we are not required to agree to your request. To request restrictions, you must send a written request to the office listed below.

Request Non-disclosure to Health Plans for Items or Services that are Self-Paid: If you pay out-of-pocket in full for health care items or services, prior to the service, and request to restrict Mass. Eye and Ear from disclosing the health care item(s) or service(s) to your Health Plan, Mass. Eye and Ear must honor the request.

Request Confidential Communications: You have the right to request that we communicate with you by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing, or at a different residence or post office box. To request confidential communication of your PHI, you must submit your request in writing to the office listed below. Your request must state how, or when, you would like to be contacted, but you do not need to tell us the reason for the confidential communication. We may request, however, that you coordinate with us to assure satisfactory means to communicate with you about, and to receive, payment for our services. We will accommodate reasonable requests.

Inspect and Obtain a Copy of Your Information: You have the right to access and copy PHI about you contained in your medical and billing records for as long as Mass. Eye and Ear maintains the information. To read or copy your PHI, you must send a written request to the office listed below. If you request a copy of the information, we may charge you a fee for the costs of the copying, mailing, or other supplies that are necessary to grant your request. We may deny your request to read and copy your PHI in certain limited circumstances. If we deny your request, you can ask us to reconsider the denial. Depending on the reason for the denial, we may ask a licensed health care professional to review your request and the denial.

Amend Your Information: If you feel that PHI we have about you is incomplete or incorrect, you may request that we amend the information. You may request an amendment for as long as we maintain your PHI. To request an amendment, you must send a written request to the office listed below. In addition, you must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement and we may provide you with a rebuttal to your statement.

Receive an Accounting of Disclosures of Your Information: You have the right to receive an accounting of the disclosures we have made of your PHI for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, disclosures made pursuant to a valid authorization, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations.

To request an accounting, you must submit your request in writing to the office listed below. Your request must specify the time period for which you are seeking an accounting, but it may not be longer than 6 years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

To make requests related to your rights above, contact:
Health Information Services
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston, Massachusetts 02114

Obtain a Paper Copy of this Notice of Privacy Practices Upon Request: You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy of the Notice. To obtain a copy of the Notice, contact the Mass. Eye and Ear Privacy Officer at the contact information below.

We are required by law to protect the privacy of your information, notify affected individuals following a breach of unsecured PHI, provide this Notice about our privacy practices, and follow the privacy practices that are described in this Notice. Mass. Eye and Ear reserves the right to change the terms of its NPP and to make the new NPP provisions effective for all PHI that it maintains. If more than one law applies to this Notice, we will follow the more stringent law.

If you have questions or would like additional information about the Mass. Eye and Ear’s privacy practices, contact the:
Privacy Officer
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston, Massachusetts 02114
844-815-4401 (anonymous Compliance Line)

If you believe your privacy rights have been violated, you can file a complaint with Mass. Eye and Ear’s Privacy Officer or with the United States Secretary of Health and Human Services at:
The Office for Civil Rights
US Department of Health and Human Services
J. F. Kennedy Building, Room 1875
Government Center
Boston, Massachusetts 02203
Fax: 617-565-3809

There will be no retaliation from Mass. Eye and Ear for filing a complaint.


Page updated October 17, 2016