PALMDALE OPTOMETRY NOTICE OF PRIVACY PRACTICES Effective Date: 4-14-03 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. OUR LEGAL DUTY We are required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this notice of its legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this Notice. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. How Palmdale Optometry May Use or Disclose Your Health Information Palmdale Optometry protects the privacy of your health information. The law permits us to use or disclose your health information for the following purposes: ? Treatment, Payment, and Regular Health Care Operations : Information obtained by Palmdale Optometry will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request. ? To You, Your Family and Friends : We must disclose your health information to you, as described in the Information Rights section of the Notice. We may disclose your health information to a family member, friend or other person to help with your healthcare or with payment for your healthcare, but only if you agree or do not object that we may do so or, if you are not able to agree, if it is necessary in our professional judgment. ? As and When Required by Law : We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), Judicial and Administrative, Deceased Person Information, Worker Compensations programs, Food & Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the Military or a Veteran of the armed forces when requested, or if you become an inmate in a correctional facility. ? Personal Communications : We may contact you to provide appointment reminders, annual eye examination cards, and other information about treatment alternatives or other health-related benefits and services that may be of interest to you as well as communicate with individuals involved in your care or payment for your care. ? Disclosure to Our Business Associates : There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose health information about you to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard the health information. ? Victims of Abuse, Neglect, or Domestic Violence : We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. ? Marketing Communications : We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatment, care, or alternative treatments, or providers without authorization. When Palmdale Optometry May Not Use or Disclose Your Health Information Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If your state law provides additional restrictions upon any of the foregoing uses and disclosures, we must follow your state law. Although all records concerning your services obtained from us are our property, you have the following rights with respect to your health information. ? Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your information. We are not required to honor your request. We encourage you to make these requests in writing. ? Right to Confidential Communications: You have the right to receive confidential communications of your information by alternative means or at alternative locations. For example, you may request that we contact you only at work or by mail. We require that you make this request in writing. ? Right to Inspect and Copy: You have the right to inspect and copy your information in most circumstances. We require that you make this request in writing. ? Right to Amend: You have the right to amend your health information in circumstances where you believe that information is inaccurate or incomplete. We require that you make this request in writing, and that you tell us why you believe that we should amend your information. ? Right to an Accounting: You have the right to request and obtain an accounting of certain disclosures of your information. You must make this request in writing. ? Right to Obtain Copy: You have the right to obtain a paper copy of this Notice upon request. A request to exercise any of these rights must be submitted to the Privacy Officer. Forms to help you make your request are available from the Privacy Officer. You may also obtain paper copies of these forms from us. Changes to this Notice of Privacy Practices Palmdale Optometry reserves the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new Notice effective for all medical information we maintain. Until such amendment is made, Palmdale Optometry is required by law to comply with this Notice. The revised notice will be posted in the office and a paper copy will be available upon request. For More Information or to Report a Problem If you have questions or would like additional information about Palmdale Optometry?s privacy practices, you may contact the Privacy Officer, at 445 West Palmdale Boulevard Suite B Palmdale, CA. 93551 or 1-661-273-4900. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation, using our form with the Secretary of the Department of Health and Human Services, Office of Civil Rights, HIPAA Privacy, 200 Independence Avenue, S.W., Washington, DC. 20201.