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NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES (“NOTlCE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH

INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

Your”health information,” for purposes of this Notice, is generally any information that identifies you and is created, received, maintained

or transmitted by us in the course of providing health care items or services to you (referred to as “health information” in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain

the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such

information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations.

Examples of how we use or disclose your health 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 must carry out 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;

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization.

• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal

• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for

• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative

• 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;

• 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

• disclosures to “business associates” and their subcontractors who perform health care operations for us and who commit to respect

Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you

with your eye care.Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment

for heath care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION

The following are some specific uses and disclosures we may not make of your health information without your authorization:

Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes

unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts

of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also

Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to

Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we

YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

• Other uses and disclosures of your health information that are not described in th is Notice will be made only with your written

• You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.

• We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are

We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of

carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care

item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at

any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the

authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We

may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you

• To request restrictions on the health information we may use and disclose for treatment, payment and health care operations.

We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.

• To receive confidential communications of health information about you in any manner other than described in our authorization

request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we will be

To inspect or copy your health information.You must make such requests in writing to the address below. If you request a copy of

your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may

To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to

amend the information . To request an amendment, you must write to us at the address below. You must also give us a reason to support

your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support

o was not c reated by us, unless the person that c reated the information is no longer available to make the amendment,

To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below .

Not all health information is subject to this request. Your request must state a time period for the information you would like to receive,

no lo nger than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your request must state how

To designate another party to receive your health information.If your request for access of your health information directs us to

transmit a copy of the health information directly to another person the request must be made by you in writing to the address below

Our contact person for all questions, requests or for further information related to the privacy of your health information is:

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to 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 Email shown above. If you prefer, you can discuss

We reserve the right to change our privacy practices and to apply lhe revised practices to health inforn1ation about you that we already have.

Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this

Notice Revised and Effective: ————- NF 5/2013

I have acknowledge that I received a copy of ———————‘ Notice of Privacy Practices.

Date —— Patient name _______________ Signature —————-