This Notice of Privacy Practices ("Notice")describes how we may use or disclose your health information and how you canget access to such information. Please read it carefully.Your"health information," for purposes of this Notice, is generally anyinformation that identifies you and is created, received, maintained ortransmitted by us in the course of providing health care items or services toyou (referred to as "health information" in this Notice).

We are required by the Health InsurancePortability and Accountability Act of 1996 ("HIPAA") and otherapplicable laws to maintain the privacy of your health information, to provideindividuals with this Notice of our legal duties and privacy practices withrespect to such information, and to abide by the terms of this Notice. We arealso required by law to notify affected individuals following a breach of theirunsecured health information. 



The most common reasons why we use or disclose your healthinformation are for treatment, payment or health care operations. Examples ofhow we use or disclose your health information for treatment purposes are:setting up an appointment for you; testing or examining your eyes; prescribingglasses, contact lenses, or eye medications and faxing them to be filled;showing you low vision aids; referring you to another doctor or clinic for eyecare or low vision aids or services; or getting copies of your healthinformation from another professional that you may have seen before us.Examples of how we use or disclose your health information for payment purposesare: asking you about your health or vision care plans, or other sources ofpayment; preparing and sending bills or claims; and collecting unpaid amounts(either ourselves or through a collection agency or attorney). "Healthcare operations" mean those administrative and managerial functions thatwe must carry out in order to run our office. Examples of how we use ordisclose your health information for health care operations are: financial orbilling audits; internal quality assurance; personnel decisions; participationin managed care plans; defense of legal matters; business planning; and outsidestorage of our records.


Other Disclosures and Uses We May Make Without YourAuthorization or Consent


In some limited situations, the law allows or requires us touse or disclose your health information without your consent or authorization.Not all of these situations will apply to us; some may never come up at ouroffice at all. Such uses or disclosures are:


·        when a state or federal law mandates that certain healthinformation be reported for a specific purpose;

·        for public health purposes, such as contagious diseasereporting, investigation or surveillance; and notices to and from the federalFood and Drug Administration regarding drugs or medical devices;

·        disclosures to governmental authorities about victims ofsuspected abuse, neglect or domestic violence;

·        uses and disclosures for health oversight activities, suchas for the licensing of doctors; for audits by Medicare or Medicaid; or forinvestigation of possible violations of health care laws;

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

·        disclosures for law enforcement purposes, such as to provideinformation about someone who is or is suspected to be a victim of a crime; toprovide information about a crime at our office; or to report a crime thathappened somewhere else;

·        disclosure to a medical examiner to identify a dead personor 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 healthor safety;

·        uses or disclosures for specialized government functions,such as for the protection of the president or high ranking governmentofficials; 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 ofpermitted uses or disclosures;

·        disclosures to "business associates" and theirsubcontractors who perform health care operations for us and who commit torespect the privacy of your health information in accordance with HIPAA;

·        [specify other uses and disclosures affected by state law].


Unlessyou object, we will also share relevant information about your care with any ofyour personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family membersor to other persons who were involved in your care or payment for heath careprior to your death (such as your personal representative) health informationrelevant to their involvement in your care unless doing so is inconsistent withyour preferences as expressed to us prior to your death.




Thefollowing are some specific uses and disclosures we may not make of your healthinformation without yourauthorization:


Marketing activities. We must obtain your authorizationprior to using or disclosing any of your health information for marketingpurposes unless such marketing communications take the form of face-to-facecommunications we may make with individuals or promotional gifts of nominalvalue that we may provide. If such marketing involves financial payment to usfrom a third party your authorization must also include consent to suchpayment.


Sale of health information. We do not currentlysell or plan to sell your health information and we must seek yourauthorization prior to doing so.


Psychotherapy notes. Although we do not create or maintainpsychotherapy notes on our patients, we are required to notify you that we generallymust obtain your authorization prior to using or disclosing any such notes.




·        Other uses and disclosures of your health information thatare not described in this Notice will be made only with your writtenauthorization.

·        You may give us written authorization permitting us to useyour health information or to disclose it to anyone for any purpose.

·        We will obtain your written authorization for uses anddisclosures of your health information that are not identified in this Noticeor are not otherwise permitted by applicable law.

·        We must agree to your request to restrict disclosure of yourhealth information to a health plan if the disclosure is for the purpose ofcarrying out payment or health care operations and is not otherwise required bylaw and such information pertains solely to a health care item or service forwhich you have paid in full (or for which another person other than the healthplan has paid in full on your behalf).

Anyauthorization you provide to us regarding the use and disclosure of your healthinformation may be revoked by you in writing at any time. After you revoke yourauthorization, we will no longer use or disclose your health information forthe reasons described in the authorization. However, we are generally unable to retract any disclosures that we mayhave already made with your authorization. We may also be required to disclosehealth information as necessary for purposes of payment for services receivedby you prior to the date you revoked your authorization.


You have many rights concerning theconfidentiality of your health information. You have the right:

·        To requestrestrictions on the health information we may use and disclose for treatment,payment and health care operations. We are not required to agree tothese requests. To request restrictions, please send a written request to usat the address below.

·        To receiveconfidential communications of health information about you in any manner otherthan described in our authorization request form. You must make suchrequests in writing to the address below. However, we reserve the right todetermine if we will be able to continue your treatment under such restrictiveauthorizations.

·        To inspect or copyyour health information. You must make such requests in writing to the addressbelow. If you request a copy of your health information we may charge you a feefor the cost of copying, mailing or other supplies. In certain circumstances wemay deny your request to inspect or copy your health information, subject toapplicable law.

·        To amend healthinformation.If you feel that health information we have about you is incorrect orincomplete, 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 tosupport your request. We may deny your request to amend your health informationif it is not in writing or does not provide a reason to support your request.We may also deny your request if the health information:

o   was not created by us, unless the person that created theinformation is no longer available to make the amendment,

o   is not part of the health information kept by or for us,

o   is not part of the information you would be permitted toinspect or copy, or

o   is accurate and complete.

·        To receive anaccounting of disclosures of your health information. You must make suchrequests in writing to the address below. Not all health information is subjectto this request. Your request must state a time period for the information youwould like to receive, no longer than 6 years prior to the date of your requestand may not include dates before April 14, 2003. Your request must state howyou would like to receive the report (paper, electronically).

·        To designate anotherparty to receive your health information. If your request for access of yourhealth information directs us to transmit a copy of the health informationdirectly to another person the request must be made by you in writing to theaddress below and must clearly identify the designated recipient and where tosend the copy of the health information.

Contact Person:

Our contact personfor all questions, requests or for further information related to the privacyof your health information is:






Ifyou think that we have not properly respected the privacy of your healthinformation, you are free to complain to us or to the U.S. Department of Healthand Human Services, Office for Civil Rights. We will not retaliate against youif you make a complaint. If you want to complain to us, send a writtencomplaint to the office contact person at the address, fax or E mail shownabove. If you prefer, you can discuss your complaint in person or by phone.


Changes to This Notice:

Wereserve the right to change our privacy practices and to apply the revisedpractices to health information about you that we already have. Any revision toour privacy practices will be described in a revised Notice that will be postedprominently in our facility. Copies of this Notice are also available uponrequest at our reception area.

NoticeRevised and Effective: _____________ ____, 20___



I acknowledge that Ireceived a copy of _________________________________O.D., Notice of PrivacyPractices.


Date ___________  Patient name________________________________Signature _______________________________