HIPAA NOTICE OF PRIVACY PRACTICES

Please read this notice carefully. It explains how we may use and disclose your health information and your rights regarding that information.

How we may use your health information:
We may use or disclose your Protected Health Information (PHI), as permitted by law, for:

  • Treatment — Providing and coordinating your eye care examinations, diagnosis, prescriptions, referrals, and communicating with other health care professionals involved in your care.
  • Payment — Billing you, your insurance company, or another responsible party and obtaining payment for services provided.
  • Health Care Operations — Managing and improving our practice, including quality assurance, billing, administrative activities, and record management.
  • Appointment Reminders — Contacting you by phone, voicemail, text, email, or mail regarding appointments, routine care, or related services.

Other uses or disclosures generally require your written authorization unless otherwise permitted or required by law. You may revoke an authorization in writing, subject to actions already taken based on that authorization.

You have the right to:

  • Request access to and copies of your health information.
  • Request that we correct or amend information you believe is inaccurate or incomplete.
  • Request restrictions on certain uses or disclosures of your information.
  • Request that we communicate with you by a particular method or at a particular location.
  • Receive a paper copy of this Notice upon request.
  • File a complaint with us or with the U.S. Department of Health and Human Services, Office for Civil Rights.

We will not retaliate against you for filing a privacy complaint.

OUR RESPONSIBILITY

We are required by law to protect the privacy of your PHI, provide you with this notice, and follow the privacy practices described in it. We may change this notice as permitted by law. The current notice will be available upon request.

PATIENT ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have received a copy of the Notice of Privacy Practices for Village Eyecare.

Patient Signature: ______________________________________________

Date: ______________________