ALLIED EYE PHYSICIANS & SURGEONS, INC.

NOTICE OF PRIVACY PRACTICES


					Date of Last 
Revision:  4/1/2003		Effective Date: Immediately

This information is made available on request by a patient

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.

THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE 
GENERATED BY THE PRACTICE, WHETHER MADE BY THE PRACTICE OR 
AN ASSOCIATED FACILITY.



This notice describes our Practice?s policies, which extend 
to:

·	Any health care professional authorized to enter 
information into your chart (including physicians, 
optometrists, nurses, technicians, medical assistants, 
etc.);
·	All areas of the Practice (front desk, 
administration, billing and collection, etc.);
·	All employees, staff and other personnel that work 
for or with our Practice;
·	Our business associates (including a billing 
service, or facilities to which we refer patients), on-call 
physicians, and so on.  

The Practice provides this Notice to comply with the 
Privacy Regulations issued by the Department of Health and 
Human Services in accordance with the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA).

OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION:

We understand that your medical information is personal to 
you, and we are committed to protecting the information 
about you.  As our patient, we create paper and electronic 
medical records about your health, our care for you, and 
the services and/or items we provide to you as our 
patient.  We need this record to provide for your care and 
to comply with certain legal requirements. 

 
We are required by law to:

·	make sure that the protected health information 
about you is kept private;
·	provide you with a Notice of our Privacy Practices 
and your legal rights with respect to protected health 
information about you; and
·	follow the conditions of the Notice that is 
currently in effect.


HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we 
use and disclose protected health information that we have 
and share with others. Each category of uses or disclosures 
provides a general explanation and provides some examples 
of uses.  Not every use or disclosure in a category is 
either listed or actually in place.  The explanation is 
provided for your general information only.  

·	Medical Treatment.  We use previously given medical 
information about you to provide you with current or 
prospective medical treatment or services.  Therefore we 
may, and most likely will, disclose medical information 
about you to doctors, nurses, technicians, medical 
students, or hospital personnel who are involved in taking 
care of you.  For example, a doctor to whom we refer you 
for ongoing or further care may need your medical record.  
Different areas of the Practice also may share medical 
information about you including your record(s), 
prescriptions, requests of lab work and x-rays. We may also 
discuss your medical information with you to recommend 
possible treatment options or alternatives that may be of 
interest to you.  We also may disclose medical information 
about you to people outside the Practice who may be 
involved in your medical care after you leave the Practice; 
this may include your family members, or other personal 
representatives authorized by you or by a legal mandate (a 
guardian or other person who has been named to handle your 
medical decisions, should you become incompetent). 

·	Payment. We may use and disclose medical 
information about you for services and procedures so they 
may be billed and collected from you, an insurance company, 
or any other third party.  For example, we may need to give 
your health care information, about treatment you received 
at the Practice, to obtain payment or reimbursement for the 
care.  We may also tell your health plan and/or referring 
physician about a treatment you are going to receive to 
obtain prior approval or to determine whether your plan 
will cover the treatment, to facilitate payment of a 
referring physician, or the like. 

·	Health Care Operations.  We may use and disclose 
medical information about you so that we can run our 
Practice more efficiently and make sure that all of our 
patients receive quality care. These uses may include 
reviewing our treatment and services to evaluate the 
performance of our staff, deciding what additional services 
to offer and where, deciding what services are not needed, 
and whether certain new treatments are effective. We may 
also disclose information to doctors, nurses, technicians, 
medical students, and other personnel for review and 
learning purposes. We may also combine the medical 
information we have with medical information from other 
Practices to compare how we are doing and see where we can 
make improvements in the care and services we offer. We may 
remove information that identifies you from this set of 
medical information so others may use it to study health 
care and health care delivery without learning who the 
specific patients are.

	We may also use or disclose information about you 
for internal or external utilization review and/or quality 
assurance, to business associates for purposes of helping 
us to comply with our legal requirements, to auditors to 
verify our records, to billing companies to aid us in this 
process and the like.  We shall endeavor, at all times when 
business associates are used, to advise them of their 
continued obligation to maintain the privacy of your 
medical records.
	
·	Appointment and Patient Recall Reminders.  We may 
ask that you sign in writing at the Receptionists' Desk, 
a "Sign In" log on the day of your appointment with the 
Practice.  We may use and disclose medical information to 
contact you as a reminder that you have an appointment for 
medical care with the Practice or that you are due to 
receive periodic care from the Practice.  This contact may 
be by phone, in writing, e-mail, or otherwise and may 
involve the leaving an e-mail, a message on an answering 
machines, or otherwise which could (potentially) be 
received or intercepted by others.

·	Emergency Situations.  In addition, we may disclose 
medical information about you to an organization assisting 
in a disaster relief effort or in an emergency situation so 
that your family can be notified about your condition, 
status and location.

·	Research.  Under certain circumstances, we may use 
and disclose medical information about you for research 
purposes regarding medications, efficiency of treatment 
protocols and the like. All research projects are subject 
to an approval process, which evaluates a proposed research 
project and its use of medical information.  Before we use 
or disclose medical information for research, the project 
will have been approved through this research approval 
process.  We will obtain an Authorization from you before 
using or disclosing your individually identifiable health 
information unless the authorization requirement has been 
waived. If possible, we will make the information non-
identifiable to a specific patient.  If the information has 
been sufficiently de-identified, an authorization for the 
use or disclosure is not required.

·	Required By Law. We will disclose medical 
information about you when required to do so by federal, 
state or local law.

·	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 either to your 
specific 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. 

·	Organ and Tissue Donation. If you are an organ 
donor, we may release medical information to organizations 
that handle organ procurement or organ, eye or tissue 
transplantation or to an organ donation bank, as necessary 
to facilitate organ or tissue donation and transplantation. 

·	Workers' Compensation.  We may release medical 
information about you for workers' compensation or similar 
programs. These programs provide benefits for work-related 
injuries or illness. 

·	Public Health Risks. Law or public policy may 
require us to disclose medical information about you for 
public health activities. These activities generally 
include the following:

·	to prevent or control disease, injury or 
disability; 
·	to report births and deaths;
·	to report child abuse or neglect;
·	to report reactions to medications or problems with 
products;
·	to notify people of recalls of products they may be 
using; 
·	to notify a person who may have been exposed to a 
disease or may be at risk for contracting or spreading a 
disease or condition;
·	to notify the appropriate government authority if 
we believe a patient has been the victim of abuse, neglect 
or domestic violence. We will only make this disclosure if 
you agree or when required or authorized by law.

·	Investigation and Government Activities.  We may 
disclose medical information to a local, state or federal 
agency for activities authorized by law. These oversight 
activities include, for example, audits, investigations, 
inspections, and licensure. These activities are necessary 
for the payor, the government and other regulatory agencies 
to monitor the health care system, government programs, and 
compliance with civil rights laws.

·	Lawsuits and Disputes. If you are involved in a 
lawsuit or a dispute, we may disclose medical information 
about you in response to a court or administrative order.  
This is particularly true if you make your health an 
issue.  We may also disclose medical information about you 
in response to a subpoena, discovery request, or other 
lawful process by someone else involved in the dispute.  We 
shall attempt in these cases to tell you about the request 
so that you may obtain an order protecting the information 
requested if you so desire.  We may also use such 
information to defend ourselves or any member of our 
Practice in any actual or threatened action. 

·	Law Enforcement. We may release medical information 
if asked to do so by a law enforcement official:

·	In response to a court order, subpoena, warrant, 
summons or similar process; 
·	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 Practice; 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 
Practice to funeral directors as necessary to carry out 
their duties. 

·	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 (1) for the institution to 
provide you with health care; (2) to protect your health 
and safety or the health and safety of others; or (3) for 
the safety and security of the correctional institution. 

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time.  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 may receive from you in the 
future. We will post a copy of the current notice in the 
Practice. The notice will contain on the first page, in the 
top right-hand corner, the date of last revision and 
effective date.  In addition, each time you visit the 
Practice for treatment or health care services you may 
request a copy of the current notice in effect. 


COMPLAINTS

If you believe your privacy rights have been violated, you 
may file a complaint with the Practice or with the 
Secretary of the Department of Health and Human Services. 
To file a complaint with the Practice, contact our office 
manager, who will direct you on how to file an office 
complaint.  All complaints must be submitted in writing, 
and all complaints shall be investigated, without 
repercussion to you. 

The Office Manager can be reached at this number:  (937) 
433-2300.

You will not be penalized for filing a complaint.


OTHER USES OF MEDICAL 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 permission, unless those uses 
can be reasonably inferred from the intended uses above.  
If you have provided us with your permission to use or 
disclose medical information about you, you may revoke that 
permission, in writing, at any time. If you revoke your 
permission, we will no longer use or disclose medical 
information about you for the reasons covered by your 
written authorization. You understand that we are unable to 
take back any disclosures we have already made with your 
permission, and that we are required to retain our records 
of the care that we provided to you.


PATIENT RIGHTS

THIS SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF 
THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR 
MEDICAL INFORMATION.

You have the following rights regarding medical information 
we maintain 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. This includes your own 
medical and billing records, but does not include 
psychotherapy notes.  Upon proof of an appropriate legal 
relationship, records of others related to you or under 
your care (guardian or custodial) may also be disclosed.

To inspect and copy your medical record, you must submit 
your request in writing to our Compliance Officer.  Ask the 
front desk person for the name of the Compliance Officer.  
If you request a copy of the information, we may charge a 
fee for the costs of copying, mailing or other supplies 
(tapes, disks, etc.) associated with your request.

We may deny your request to inspect and copy in certain 
very limited circumstances. If you are denied access to 
medical information, you may request that our Compliance 
Committee review the denial. Another licensed health care 
professional chosen by the Practice will review your 
request and the denial. The person conducting the review 
will not be the person who denied your request. We will 
comply with the outcome and recommendations from that 
review. 

·	Right to Amend. If you feel that the medical 
information we have about you in your record is incorrect 
or incomplete, then you may ask us to amend the 
information, following the procedure below.  You have the 
right to request an amendment for as long as the Practice 
maintains your medical record.

To request an amendment, your request must be submitted in 
writing, along with your intended amendment and a reason 
that supports your request to amend.  The amendment must be 
dated and signed by you and notarized.

We may deny your request for an amendment if it is not in 
writing or does not include a reason to support the 
request. In addition, we may deny your request if you ask 
us to amend information that:

·	Was not created by us, unless the person or entity 
that created the information is no longer available to make 
the amendment;
·	Is not part of the medical information kept by or 
for the Practice;
·	Is not part of the information which you would be 
permitted to inspect and copy; or 
·	Is inaccurate and incomplete.

·	Right to an Accounting of Disclosures. You have the 
right to request an "accounting of disclosures." This is a 
list of the disclosures we made of medical information 
about you, to others. 

To request this list, you must submit your request in 
writing. Your request must state a time period not longer 
than six (6) years back and may not include dates before 
April 14, 2003 (or the actual implementation date of the 
HIPAA Privacy Regulations).  Your request should indicate 
in what form you want the list (for example, on paper, 
electronically). We will notify you of the cost involved 
and you may choose to withdraw or modify your request at 
that time before any costs are incurred. 

·	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. You also have the right 
to request a limit on the medical information we disclose 
about you to someone who is involved in your care or the 
payment for your care (a family member or friend). For 
example, you could ask that we not use or disclose 
information about a particular treatment you received. 

We are not required to agree to your request and we may not 
be able to comply with your request.  If we do agree, we 
will comply with your request except that we shall not 
comply, even with a written request, if the information is 
excepted from the consent requirement or we are otherwise 
required to disclose the information by law. 

To request restrictions, you must make your request in 
writing. In your request, you indicate:

·	what information you want to limit; 
·	whether you want to limit our use, disclosure or 
both; and 
·	to whom you want the limits to apply, (e.g., 
disclosures to your children, parents, spouse, etc.)

·	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, that we not leave voice mail or e-
mail, or the like.

To request confidential communications, you must make your 
request in writing. We will not ask you the reason for your 
request.  We will accommodate all reasonable requests. Your 
request must specify how or where you wish us to contact 
you.

·	Right to a 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. Even if you 
have agreed to receive this notice electronically, you are 
still entitled to a paper copy of this notice.