INSTITUTE FOR TOTAL EYE CARE, P.C. AND CARMICHAEL OPTICAL SHOPPE 4255 Carmichael Court North Montgomery, AL36106 (334) 277-9111 or (334) 277-7677 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can gain access to this information.Please review it carefully. If you have any questions about this Notice, please contact our Practice Administrator. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.It also describes your rights to access and control your protected health information."Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices.We may change the terms of our notice at any time.The new notice will be effective for all protected health information that we maintain at that time.Upon your request, we will provide you with any revised Notice of Privacy Practices at the time of your next visit. Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object. We may use or disclose your protected health information in the following situations without your consent or authorization.These situations include: Required by Law:Use or disclosure of your protected health information will be made in compliance with the law and will be limited to relevant requirements of the law.You will be notified, as required by law, of any such uses or disclosures. Public Health:Only to the extent as permitted by law, disclosure of your protected health information will be made for the purpose of controlling disease, injury or disability. Communicable Diseases:We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight:We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect:We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.In addition, we may disclose your protected health 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. Food and Drug Administration:We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biological product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings:We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement:We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.These law enforcement purposes include (1) legal processes and as otherwise required by law, (2) limited information requests for identification and local purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice's premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation:We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties as authorized by law.We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.We may disclose such information in a reasonable anticipation of death.Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. Research:We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity:Consistent with the applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lesson a serious and imminent threat to the health or safety of a person or the public.We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity or National Security:When appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran's Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military's services.We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others as legally authorized. Worker's Compensation: we may disclose your protected health information as authorized to comply with worker's compensation laws and other similar legally established programs. Inmates:We may disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Required Uses and Disclosures:Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq. Your Rights Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information.This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information.A "designated record set" contains medical and billing records and any other records that your physician and the practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records, psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.Depending on the circumstances, a decision to deny access may be subject to review.In some circumstances, you may have a right to have this decision reviewed.Please contact our Practice Administrator if you have questions about access to your medical record. You have the right to request a restriction of your protected health information.This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations.You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request.If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.If your physician does agree to a requested restriction, we may not disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.With this in mind, please discuss any restriction you wish to request with your physician.You may request a restriction by asking for the proper form at the front desk. You have the right to request and to receive confidential communication from us by alternative means or at an alternative location.We will accommodate reasonable requests.We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.We will not request an explanation from you as to the basis for the request.Please make this request in writing to the front desk. You may have the right to have your physician amend your protected health information.This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information.In certain cases, we may deny your request for an amendment.If we deny your request for amendment, you have the right to file a statement of disagreement with use, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.Please contact our Practice Administrator to determine if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.It excludes disclosure we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes.You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.You may request a shorter timeframe.The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you may have agreed to accept this notice electronically. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.You may file a complaint with us by notifying our Practice Administrator of your complaint.We will not retaliate against you for filing a complaint. You may contact our Practice Administrator at (334) 277-9111 or by mail at 4255 Carmichael Court North, Montgomery, Alabama, 36106, for further information about the complaint process. This notice was published and becomes effective on April 14, 2003.