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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.
We respect our legal obligation to keep health information that
identifies you private. We are obligated by law to give you notice of
our privacy practices. This Notice describes how we protect your
health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health
information is for treatment, payment or health care operations.
Examples of how we use or disclose information for treatment
purposes are: setting up an appointment for you; testing or
examining your eyes; prescribing glasses, contact lenses, or eye
medications and faxing them to be filled; showing you low vision
aids; referring you to another doctor or clinic for eye care or low
vision aids or services; or getting copies of your health information
from another professional that you may have seen before us.
Examples of how we use or disclose your health information for
payment purposes are: asking you about your health or vision care
plans, or other sources of payment; preparing and sending bills or
claims; and collecting unpaid amounts (either ourselves or through
a collection agency or attorney). “Health care operations” mean
those administrative and managerial functions that we have to do in
order to run our office. Examples of how we use or disclose your
health information for health care operations are: financial or billing
audits; internal quality assurance; personnel decisions;
participation in managed care plans; defense of legal matters;
business planning; and outside storage of our records.
We routinely use your health information inside our office for these
purposes without any special permission. If we need to disclose
your health information outside of our office for these reasons, we
usually will not ask you for special written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT
PERMISSION
In some limited situations, the law allows or requires us to use or
disclose your health information without your permission. Not all of
these situations will apply to us; some may never come up at our
office at all. Such uses or disclosures are:
?? when a state or federal law mandates that certain health
information be reported for a specific purpose;
?? for public health purposes, such as contagious disease
reporting, investigation or surveillance; and notices to and from
the federal Food and Drug Administration regarding drugs or
medical devices;
?? disclosures to governmental authorities about victims of
suspected abuse, neglect or domestic violence;
?? uses and disclosures for health oversight activities, such as for
the licensing of doctors; for audits by Medicare or Medicaid; or
for investigation of possible violations of health care laws;
?? disclosures for judicial and administrative proceedings, such
as in response to subpoenas or orders of courts or
administrative agencies;
?? disclosures for law enforcement purposes, such as to provide
information about someone who is or is suspected to be a
victim of a crime; to provide information about a crime at our
office; or to report a crime that happened somewhere else;
?? disclosure to a medical examiner to identify a dead person or
to determine the cause of death; or to funeral directors to aid in
burial; or to organizations that handle organ or tissue
donations;
?? uses or disclosures for health related research;
?? uses and disclosures to prevent a serious threat to health or
safety;
?? uses or disclosures for specialized government functions, such
as for the protection of the president or high ranking
government officials; for lawful national intelligence activities;
for military purposes; or for the evaluation and health of
members of the foreign service;
?? disclosures of de-identified information;
?? disclosures relating to worker’s compensation programs;
?? disclosures of a “limited data set” for research, public health, or
health care operations;
?? incidental disclosures that are an unavoidable by-product of
permitted uses or disclosures;
?? disclosures to “business associates” who perform health care
operations for us and who commit to respect the privacy of
your health information;
Unless you object, we will also share relevant information about
your care with your family or friends who are helping you with
your eye care.
APPOINTMENT REMINDERS
We may call, write, or electronically remind you of scheduled
appointments, or that it is time to make a routine appointment.
We may also call, write, or electroncially notify you of other
treatments or services available at our office that might help you.
Unless you tell us otherwise, we will mail you an appointment
reminder on a post card, letter, or through e-mail, and/or leave
you a reminder message on your home answering machine or
with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health
information unless you sign a written “authorization form.” The
content of an “authorization form” is determined by federal law.
Sometimes, we may initiate the authorization process if the use
or disclosure is our idea. Sometimes, you may initiate the
process if it’s your idea for us to send your information to
someone else. Typically, in this situation you will give us a
properly completed authorization form, or you can use one of
ours.
If we initiate the process and ask you to sign an authorization
form, you do not have to sign it. If you do not sign the
authorization, we cannot make the use or disclosure. If you do
sign one, you may revoke it at any time unless we have already
acted in reliance upon it. Revocations must be in writing. Send
them to the office contact person named at the beginning of this
Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information.
You can:
?? ask us to restrict our uses and disclosures for purposes of
treatment (except emergency treatment), payment or health
care operations. To ask for a restriction, send a written request
to the office contact person at the address, fax or e-mail shown
at the beginning of this Notice.
?? ask us to communicate with you in a confidential way. We will
accommodate these requests if they are reasonable, and if
you pay us for any extra cost. To ask for confidential
communications, send a written request to the office contact
person at the address, fax or e-mail shown at the beginning of
this Notice.
?? ask to see or to get photocopies of your health information. By
law, there are a few limited situations in which we can refuse
to permit access or copying. Generally you will be able to
review or have a copy of your health information within 30
days of asking us (or sixty days if the information is stored offsite).
You may have to pay for photocopies in advance. If we
deny your request, we will send you a written explanation, and
instructions about how to get an impartial review of our denial
if one is legally available. By law, we can have one 30 day
extension of the time for us to give you access or photocopies
if we send you a written notice of the extension. To review or
get photocopies of your health information, send a written
request to the office contact person at the address, fax or email
shown at the beginning of this Notice.
?? ask us to amend your health information if you think that it is
incorrect or incomplete. If we agree, we will amend the
information within 60 days from when you ask us. We will
send the corrected information to persons who we know got
the wrong information, and others that you specify. If we do
not agree, you can write a statement of your position, and we
will include it with your health information along with any
rebuttal statement that we may write. Once your statement of
position and/or our rebuttal is included in your health
information, we will send it along whenever we make a
permitted disclosure of your health information. By law, we
can have one 30 day extension of time to consider a request
for amendment if we notify you in writing of the extension.
To ask us to amend your health information, send a written
request, including your reasons for the amendment, to the
office contact person at the address, fax or e-mail shown at the
beginning of this Notice.
?? get a list of the disclosures that we have made of your health
information within the past six years (or a shorter period if you
want). This office is not required to account for disclosures
made prior to the effective date. By law, the list will not include:
disclosures for purposes of treatment, payment or health care
operations; disclosures with your authorization; incidental
disclosures; disclosures required by law; and some other
limited disclosures. You are entitled to one such list per year
without charge. If you want more frequent lists, you will have
to pay for them in advance. We will usually respond to your
request within 60 days of receiving it, but by law we can have
one 30 day extension of time if we notify you of the extension
in writing. For a list, send a written request to the office
contact person at the address, fax or e-mail shown at the
beginning of this Notice.
?? get additional paper copies of this Notice of Privacy Practices
upon request. For additional paper copies, send a written
request to the office contact person at the address, fax or email
shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy
Practices until we choose to change it. We reserve the right to
change this notice at any time as allowed by law. If we change this
Notice, the new privacy practices will apply to your health
information that we already have as well as to such information that
we may generate in the future. If we change our Notice of Privacy
Practices, we will post the new notice in our office, have copies
available in our office, and post it on our Web site.
COMPLAINTS
If you think that we have not properly respected the privacy of your
health information, you are free to complain to us or the U.S.
Department of Health and Human Services, Office for Civil Rights.
We will not retaliate against you if you make a complaint. If you
want to complain to us, send a written complaint to the office
contact person at the address, fax or e-mail shown at the beginning
of this Notice. If you prefer, you can discuss your complaint in
person or by phone.
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
Revision Date: April 14, 2003

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