HIPPA Privacy Statement

Effective April 14, 2003

NOTICE OF PRIVACY PRACTICES

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

Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") we are required to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to such protected health information.

We are required to abide by the terms of the notice currently in effect. We reserve the right to change the terms of our notice at any time and to make the new notice provisions effective for all protected health information that we maintain. In the event that we make a material revision to the terms of our notice, you will receive a revised notice within 60-days of such revision. If you should have any questions or require further information, please contact our Privacy Officer at 954-917-2286, ext 25.

Our Pledge Regarding Health Information

SOUTH FLORIDA VISION CENTERS is committed to protecting medical information about you. This Notice describes the privacy practices and that of all its departments and units, all employees, staff, and services of all of its affiliates.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:

• Make sure that medical information that identifies you is kept private;
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the Notice that is currently in effect.

How We May Use And Disclose Health Information About You.

The following categories describe different ways that we use and disclose Private Health Information (PHI). For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to your Primary Care Physician, Referral Physicians (Ophthalmologists, Optometrists), etc. For example, an Optometrist/Ophthalmologist treating you for a medical condition of the eye may need to know if you have diabetes because diabetes may affect your vision.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at our offices may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about the services you received at our office so your health plan will pay us or reimburse you for the office visit. We may also tell your health plan about a referral you may require to obtain prior approval or to determine whether your plan will cover the treatment.
• For Health Care Operations. We may use and disclose medical information about you for Specialty Care (Ophthalmology) These uses and disclosures are necessary to the referring physician (Ophthalmologists) and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine the medical information we have with medical information from other physicians to compare how we are doing and see where we can make improvements in the care and services we offer.
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment at our office.
• Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
• Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your vision care needs. We may also give information to someone who helps pay for your care. We may also tell your family or friends your visual needs to help assist with your needs.
• Research. Under certain circumstances, we may use and disclose medical 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. Before we use or disclose medical information for research, the project will have been approved through a research approval process.
• To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
• For special purposes. We may disclose medical information about you for special purposes as permitted or required by law, including the following:
  • Community and public health activities and reports such as disease control, abuse or neglect, and health and vital statistics.
  • Administrative oversight for such things as audits, investigations, licensure, or determining cause of death.
  • Court order or other legal processes related to law enforcement activities including custody of inmates, legal actions, or national security activities.
  • Military and veteran reporting on members of the armed forces of U.S. or foreign military as required by military command authorities.
  • Organ and tissue donation and transplant reports as required by regulatory organizations as necessary to facilitate organ or tissue donation and transplant.
  • Workers’ compensation or other rehabilitative activities reporting as required by law or insurers in order to provide benefits for work-related or victim injuries or illnesses.
  • Law enforcement if asked to do so by a law enforcement official:
    • To identify or locate a suspect, fugitive, material witness, or missing person;
    • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
    • About a death we believe may be the result of criminal conduct;
    • About criminal conduct at the Hospital; and
    • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
  • Coroners, medical examiners and funeral directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the Hospital to funeral directors as necessary to carry out their duties.
  • National security and intelligence activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Protective services for the President and others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President or other authorized persons or foreign heads of state.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary:
    • for the institution to provide you with health care;
    • to protect your health and safety or the health and safety of others; or
    • for the safety and security of the correctional institution.

Other Uses Of Health Information

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us an authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by the written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provide to you.

Your Rights Regarding Health Information About You

• Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS, 2900 West Cypress Creek Road, Suite 4 , Fort Lauderdale, FL 33309. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
• Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to add a statement. To request an amendment, your request must be made in writing and submitted to the PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS, 2900 West Cypress Creek Road, Suite 4, 400, Fort Lauderdale, FL 33309. In addition, you must provide a reason that supports your request.
• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of certain disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS, 2900 West Cypress Creek Road, Suite 4, 400, Fort Lauderdale, FL 33309. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. We are not required by federal regulation to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS, 2900 West Cypress Creek Road, Suite 4, 400, Fort Lauderdale, FL 33309.Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS, 2900 West Cypress Creek Road, Suite 4, 400, Fort Lauderdale, FL 33309. We will not ask you the reason for your request.
• Right to Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our office.

In addition, the next time you register at our office, we will offer you a copy of the current Notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with SOUTH FLORIDA VISION CENTERS or with the Secretary of the Department of Health and Human Services.

To file a complaint with the SOUTH FLORIDA VISION CENTERS, you must submit your complaint in writing to:

PRIVACY OFFICER at SOUTH FLORIDA VISION CENTERS
2900 West Cypress Creek Road, Suite 4, 400
Fort Lauderdale, FL 33309.

If you wish to discuss your complaint, you may call the Patient Advocate at 954-917-2286, ext 25. You will not be penalized in any way for filing a complaint.