This notice describes how medical information about you may be used and disclosed,
and how you can obtain access to this information. Please review it carefully. 
General Rule
We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices. Generally, we can only use your health information in our office or disclose it outside of our office, without your written permission, for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.

Uses or Disclosures of Health Information

Examples of how we use information for treatment purposes:
· When we set up an appointment for you.
· When our technician or doctor tests your eyes.
· When the doctor prescribes glasses or contact lenses.
· When the doctor prescribes medication.
· When the staff helps you select and order glasses or contact lenses.
· When we show you other vision aids.

We may disclose your health information outside of our office for treatment purposes, for example:
· If we refer you to another doctor or clinic for eye care or vision aids or services.
· If we send a prescription for glasses or contacts to another professional to be filled.
· When we provide a prescription for medication to a pharmacist.
· When we phone to let you know that your glasses or contact lenses are ready to be picked up.

Sometimes we may ask for copies of your health information from another professional that you may have seen before. We may use your health information within our office or disclose your health information outside of our office for payment purposes.

Some examples are:

When staff asks you about health or vision plans that you may belong to, or about other sources of payment for our services.
When we prepare bills to send to you or your health or vision care plan.
When we process payment by credit card and when we try to collect unpaid amounts due.
When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan.
When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.
We use and disclose your health information for healthcare operations in a number of ways. Healthcare operations mean those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for defense of legal matters, to develop business plans, and for outside storage of our records.

Appointment Reminders
We may call to remind you of scheduled appointments. We may also call to notify you of treatments or services available at our office that may help you. 

Uses & Disclosures without an Authorization
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 happen at our office at all. Such uses or disclosures are:

A state or federal law that mandates certain health information be reported for a specific purpose. Public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the 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, audits by Medicare or Medi-Cal, or investigation of possible violations of healthcare laws.

Disclosures for judicial and administrative proceedings, such as response to subpoenas, court orders 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 crim 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.
Family Optometry Center 1559 Farmers Lane, Santa Rosa, CA 95405
707 571 2020 www.familyoptometrycenter.com drm@familyoptometrycenter.com
Ian J. Middleton, OD, FAAO, privacy officer

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 relating to workers’ compensation programs.

Disclosures to business associates who perform healthcare operations for us and agree to keep your health
information private.

Other Disclosures

 We will not make any other uses or disclosures of your health information unless you sign a written authorization form.  You do not have to sign such a form. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. 

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 healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions you requested. For a restriction, send a written request to the attention of the privacy officer at the address, fax or email shown on the other side. 

You can ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using email to your personal email address. We will
accommodate these requests if they are reasonable. There may be a nominal fee for such requests. If you want to
ask for confidential communications, send a written request to the attention of the privacy officer at the address, fax
or email shown on the other side.

You can ask to see or obtain photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. Primarily, you will be able to review or have a copy of your health information within 30 days of your request. 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 required. By law, we can have one 30 day extension for us to give you access or photocopies if we provide you with a written notice of the extension. If you want to review or get photocopies of your health information, send a written request our office.

You can 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 form the date of your request. We will send the corrected information to relevant persons with which the amendment needs to be shared, and any others 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 rebuttal is included in your health information, we will include it whenever we make any subsequent, permitted disclosures of this health information. By law, we’re entitled to one 30 day extension of time to consider a request for amendment and are required to notify you in writing of the extension. If you request an amendment to your health information, send a written request, including your reasons for the amendment, to the attention of the Privacy Officer at this address.

You can obtain a list of the disclosures of your health information within the past six years, except for the following disclosures: for purposes of treatment, payment or health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. There will be a fee for additional lists. We will respond to your request within 60 days of receiving it. By law we are entitled to one 30 day extension and we are required to notify you of the extension in writing. To obtain a list, send a written request to the Privacy Officer at our office.

Our Notice of Privacy Practices
By law, we must abide by the terms of this Notice of Privacy Practices. We are also required by law to maintain the privacy of your personal health information and provide you with notice of its legal duties and privacy practices. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to all of your health information that we maintain, as well as to 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 and have copies available in our office.

Complaints
If you think that we have not properly respected the privacy of your health information, you may file a written complaint to us or to the U.S. Dept. of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint. Send a written complaint to our privacy officers at the address on the other side of this notice

For More Information
If you want more information about our privacy practices, call, write or email the privacy officers listed at the beginning of this notice.
info@familyoptometrycenter.com

HIPAA

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