Effective: September 23, 2013
Regional Eye Center
SUMMARY OF NOTICE OF PRIVACY PRACTICES
Our Legal Duty: We have a duty to protect the confidentiality of medical information about you. We are required to provide you with a
Notice of Privacy Practices explaining ways we may use and disclose your medical information. The Notice also describes your legal rights and
our obligations regarding the use and disclosure of your medical information.
Parties Following The Notice: The Notice will be followed by the office and its affiliates, together with their health care professionals,
staff and volunteers: members of the office staff and those participating managed care networks with the office; and other legal entities that
provide services to the office.
How We May Use and Disclose Medical Information About You: We may use or disclose identifiable health information about
you for many reasons, including:
* Treatment * Activities of managed care networks in which we participate
* Payment * Activities of our affiliates
* Health care operations * Appointment reminders
* Health oversight activities * As required by law
* Public health purposes * To avert a serious threat to health or safety
* Auditing * Lawsuits and disputes
* National security and protective services * Workers’ Compensation
* Research * Law Enforcement purposes
* Transportation * Schools
How We May Not Use and Disclose Medical Information About You: In general, other uses and disclosures of your medical
information will require your written authorization. We may use or disclose certain limited information about you, unless you object or request a
limitation of the disclosure, for:
* Individuals involved in your care or payment, such as friends, family, pharmacy, physicians, laboratories, insurance, Vocational
Rehab, other health care organizations, office directory, and fundraising.
* If you are paying for your services out of pocket, you may request that we not release the information to your insurer.
* We will not sell your health information.
Your Privacy Rights:
You have the following rights with respect to your health information:
* The right to request confidential communications and alternative means of communication with you.
* The right to request restrictions on certain uses of your health information.
* The right to inspect and copy certain medical information that we maintain about you.
* The right to request an electronic copy of your health information.
* The right to request corrections to your health information.
* The right to get a list of those with whom we’ve shared your health information.
Changes to the Notice: We reserve the right to change the Notice. We will post any revised Notice in the Office.
Complaints: If you believe your rights have been violated, you may file a written complaint with the Public Information Officer, P. O. Box
788, Americus, GA 31709, or with the Secretary of the U. S. Department of Health and Human Services.
Please Print Patient’s Name: ________________________________
Patient Acknowledgment: I acknowledge that I have had an opportunity to read the Notice of Privacy Practices for Regional Eye Center.
In receiving the Notice, I also acknowledge that I have been provided with an opportunity to ask questions regarding the Notice and its contents.
Signature of Patient/Guardian: ______________________________________ Date: ___________________
For Use by Office Personnel Only: (Complete if patient acknowledgment is not obtained)
The patient was provided with an opportunity to read the Notice of Privacy Practices and a good faith attempt was made to obtain the patient’s
signature acknowledging the Notice of Privacy Practices. An acknowledgment was not obtained because _______
Signature of Office Representative: __________________________ Date: ___________________
Privacy Contact Officer: Chanh Tu