This document is an abbreviated ‘Notice of Privacy Practices’. It explains how health information about you may be used, and your rights, regarding the use of that information. Please review it carefully.

You have the right to:
• Ask to see, read and/or obtain a copy of your health record (charges may be necessary)
• Ask to correct information that you believe is wrong in your health record
• Ask that your health information not be used for certain purposes, for example, research
• Ask that copies of your health record be sent to whomever you wish (charges may be necessary)
• Be informed about who has read your record (for reasons other than treatment, payment, and program Improvement purposes).
• Specify where and how you should be contacted
• Receive a paper copy of the full ‘Notice of Privacy Practices

Who is authorized to see confidential Patient Health Information (PHI)?
The “Notice of Privacy Practices” describes the ways in which your PHI may be used without obtaining the patient’s specific authorization. Certain uses such as for Treatment, Payment and health care Operations are permitted.
1. Treatment of the patient, such as consultation between treating providers
2. Payment of health care bills (insurance claim submission, authorizations and payment posting)
3. Health care operations and business operations, including research (when approved by the IRB Institutional Review Board and with a patient’s written permission); health care communications between a patient and their health care practitioner.

Written Authorizations
To use or disclose PHI for almost any other reason, you will need to sign a written authorization prior to access or disclosure. Refer to the “Notice of Privacy Practices” for a list of covered exceptions to the authorization requirement related to public policy, certain health disease reporting requirements and law enforcement activities. If you do not understand or know what you can do with PHI, please read the “Notice of Privacy Practices”.

Exceptions to the Rules
Under HIPAA, there are certain exceptions to these general rules. These exceptions are described in the “Notice of Privacy Practices”. Disclosures can be made without patient authorization: subject to professional judgment, for public health and safety purposes, for government functions, law enforcement, and based on a judicial request or subpoena. If you have concerns about how your health information might be (or has been) shared, please speak with your practitioner or the privacy coordinator. If you believe your privacy rights have NOT been maintained you may file a complaint with the Secretary, the address is U.S. Dept. of Health and Human Services, Office of Civil Rights, Attn: Regional Manager, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111. You will not be penalized in any way for filing a complaint.

• I acknowledge I reviewed a copy of Family Eye Care Center’s “Notice of Privacy Practices” and “Patient’s Rights”. I understand that my signature does not authorize disclosure, but only acknowledges that I have reviewed the “Notice of Privacy Practices” and “Patient’s Rights” and may receive a copy upon request.
• I understand and acknowledge that I may receive appointment reminder calls, newsletters, and cards, and I agree to receive these.