NOTICE OF PRIVACY PRACTICES—PACIFIC EYECARE

This Notice of Privacy Practices is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA) for 1996.

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.

Pacific EyeCare respects your privacy. We understand that your Personal Health Information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

For payment:

For health care operations:

Your Health Information Rights

The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you. You have a right to:

For help with these rights during normal business hours, please contact:

Office Manager, 360-779-2020, at our office here at 20669 Bond Rd., N.E.
Poulsbo, WA 98370. You may also contact your Physician at the same address.

Our Responsibilities

We are required to:

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up.

To Ask for Help or Complain

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Office Manager, 20669 Bond Rd., N.E., Poulsbo, WA 98370, 360-779-2020. You may also contact your Physician at the same address.

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the Office Manager as stated above. You may also file a complaint with the U.S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

· Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts.

You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

We may use and disclose your protected health information without your authorization as follows:

Other Uses and Disclosures of Protected Health Information

Web Site

Effective Date:

April 14, 2003

 

NOTICE OF PRIVACY PRACTICES—PACIFIC EYECARE OF POULSBO

This notice of Privacy Practices is required by the Privacy Regulations created as a result of the Health

Insurance Portability and Accountability Act (HIPPA) of 1996

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.

Pacific EyeCare of Poulsbo respects your privacy. We understand that your

personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

For payment:

For health care operations:

Your Health Information Rights

The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you. You have a right to:

For help with these rights during normal business hours, please contact:

Linda Welling, Office Manager

360-779-2020 ext 220 or 1-800-562-2020 ext 220

Our Responsibilities

We are required to:

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up.

To Ask for Help or Complain

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Linda Welling, Office Manager

1-360-779-2020 ext 220 or 1-800-562-2020 ext 220

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the office manager at Pacific EyeCare of Poulsbo. You may also file a complaint with the U.S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

Other Uses and Disclosures of Protected Health Information

Web Site

Effective Date:

April 14, 2003