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HIPAA Notice of Privacy Practices

Effective Date: 6/13/2019


This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). You should read this document carefully. It describes how we may use and disclose your protected health information for purposes of treatment or payment, and for other purposes that are permitted or required by law. It also explains your rights to access and control your protected health information (“PHI”). PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical condition and related health care services, or payment for health care services.


We are committed to protecting health information about you. We are required by law to ensure that PHI that identifies you is kept private; give you this notice of our legal duties and privacy practices regarding your protected health information; follow the terms of the notice that is currently in effect; and notify you in the event of a breach of your PHI. We are required to follow the terms of this HIPAA Notice of Privacy Practices. We understand that medical information about you and your health is personal.


In the course of conducting our business, we will create records regarding you and the services we provide to you. Your health record is the physical property of the healthcare practitioner or facility that compiled it, but the content is about you and therefore belongs to you. Therefore you have the right to:

  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we have shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated


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 change the terms of this HIPAA Notice of Privacy Practices. Any revision to this notice will be effective for all of your records that we have created or maintained in the past, and for any of your records that we may create or maintain in the future. When the HIPAA Notice of Privacy Practices has been revised, we will post a copy of the revised Notice in our offices in a visible location. You may request a copy of our most current Notice at any time. We will also post our most current Privacy Practices on our web site.


The following categories describe the different ways in which we may use and disclose your PHI without your authorization. For each category of use or disclosure, an explanation follows to explain what we mean and to present some examples. Not every use or disclosure in a category is listed.

Payment: Our business may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your optometrist to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items.

Health Care Operations: We may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, unless you object, we may use PHI to make and customize glasses for you. We may also use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our business.

Related Benefits and Services: Our business may use and disclose your PHI to inform you of related benefits or services that may be of interest to you. Personal Representatives: A person is your personal representative only if they have authority by law to act on your behalf in making decisions related to health care. They then must be given the same consideration as you and we may disclose your PHI to them. We may require your personal representative to produce evidence of his/her authority to act on your behalf. We may not recognize him/her if we have a reasonable belief that treating such person as your personal representative could endanger you and we decide that it is not in your best interest to treat them as your personal representative. In addition, in the event of your death, an executor, administrator, or other person authorized under the law to act on behalf of you or your estate will be treated as your personal representative. You may also be a personal representative by law for another individual in your family, such as a minor child or an incapacitated adult. Minor children may have some rights as specified in state consent laws that relate directly to minors.

Business Associates: Some of your health information may be subject to disclosure through contract services to assist this office in providing health care. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.


Our business may also use and disclose your protected health information in the following situations without your authorization. These situations include the following:

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

Public Health Risks: Our business is required by law to disclose PHI to public health and/or legal authorities, as required by law.

Abuse and Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your PHI to a governmental authority or agency authorized to receive such information, if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.


You can complain if you feel we have violated your rights. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you in any way for filing a complaint.