NOTICE OF PRIVACY PRACTICES AS REQUIRED BY THE PRIVACY REGULATIONS CREATED AS A RESULT OF THE HEATH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)

PREMIER EYECARE OF ROSWELL

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (PHI In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated but we must provide you with the following important information:

• How we may use and disclose your PHI.
• Your privacy rights in your PHI.
• Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. PLEASE ADDRESS ALL QUESTIONS ABOUT THIS NOTICE OF PRIVACY TO OUR PRIVACY OFFICER AT THE ADDRESS LISTED AT THE END OF THIS NOTCE.

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS.

The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. We use information for treatment purposes when, for example, we set up an appointment for you, when our doctor tests your eyes, when our doctor prescribes glasses, contact lenses or medication, when our staff helps you select and order glasses or contact lenses, and when we show you low vision aids. We may disclose your health information outside of our office for treatment purposes if, for example, we refer you to another doctor or clinic for further care, if we send a prescription for glasses or contacts to a laboratory to be fabricated, when we provide a prescription for medication to a pharmacist, or 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 us to allow us to treat you more efficiently.

2. Payment. We use your health information for payment purposes when, for example, our staff asks you about health or vision care 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 vison care plan, when we process payment by credit card, and when we try to collect unpaid amounts due. We may disclose your health information outside of our office for payment purposes when, for example, bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan, or when we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.

3. Health Care Operations. We use and disclose your health information for health care operations in a number of ways. Health care operations, refers to 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 the defense of legal matters, to develop business plans, and outside storage of our records.

4. Appointments and Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment or as a follow up on treatment. For example, we may send appointment reminder and recall cards to remind you of an upcoming office visit via mail, phone or email.

5. Non-Medical communications. Our practice may use you PHI to contact you for non-medical reasons. For example, we may send you a birthday card, a holiday greeting or thank you for referrals via mail or email.

6. Treatment Options. Our practice may use your PHI to inform you of potential treatment options or alternatives. We may treat you in an open treatment area and some incidental PHI may be overheard by other patients being treated at the same time.

7. Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. For example, we may send you newsletters that may include information about our practice, health related issues and products and services.

8. Release of Information to Family/Friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to the child’s medical information. This information will be released only with a complete and current release of information form on file.

9. Disclosures Required by Law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

A. Maintaining vital records, such as births and deaths;

B. Reporting child abuse or neglect;

C. Preventing or controlling disease, injury or disability;

D. Notifying a person regarding potential exposure to a communicable disease; E. Notifying a person regarding a potential risk for spreading or contracting a disease or condition;

F. Reporting reactions to drugs or problems with products or devices;

G. Notifying individuals if a product or device they may be using has been recalled;

H. Notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; and

I. Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose you PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding.

4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

A. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;

B. Concerning a death we believe has resulted from criminal conduct;

C. Regarding criminal conduct at our offices;

D. In response to a warrant, summon, court order, subpoena or similar legal process;

E. To identify/locate a suspect, material witness, fugitive or missing person; and

F.  In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator

5. Deceased Patients. For example, we may release PHI to a medical examiner, coroner or funeral director in order for them to perform their jobs.

6. Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process, which evaluates a proposed research project and it use of health information, trying to balance the research needs with a patient’s need for privacy.

8. Serious Threats to Health or Safety. For example, we may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.

9. Military. For example, we may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National Security. For example, we may disclose your PHI to federal officials for intelligence and national security activities authorized by law.

11. Inmates. For example, we may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

12. Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOU PHI

You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to our Privacy Officer. Your request must describe in a clear and concise fashion:

A. The information you wish restricted;

B. Whether you are requesting to limit our practice’s use, disclosure or both; and

C. To whom you want the limits to apply.

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Privacy Officer in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete: (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to our Privacy Officer.

All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. You understand that we are unable to take back any uses and disclosures that we have already made based on your authorization. Please note we are required to retain records of your care.

Please contact our Privacy Officer in writing at the address below:

330 E. Crossville Road

Roswell, GA 30075

Effective Date of this notice: April 14, 2003