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NOTICE OF PRIVACY PRACTICES
Shepherd Hills Eye Care Center
5940 Hamilton Boulevard, Ste C, Allentown, PA 18106
610-481-9200 | Fax: 610-481-0289

Office contact person: Dr. Richard Wiscount
Effective date of notice: April 14, 2003

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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.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

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We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing and placing orders for eyeglasses or contact lenses for you; prescribing eye medications and faxing or phoning them in to be filled; referring you to another doctor or clinic for eye care or medical services; or sending a report of your examination findings to a health care provider who referred you to us or to whom we are referring you. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims to you or a third party such as a health or vision insurance company; and collecting unpaid amounts (either ourselves or through a collection agency). "Health care operations" include quality assessment and improvement activities, reviewing the competence or qualifications of our healthcare professionals, evaluation of practitioner performance; and conducting accreditation, certification, licensing or credentialing activities.

As part of our normal offices procedures, we routinely use your health information inside our office for those purposes outlined above without obtaining any special permission. If we need to disclose your health information outside of our office for these same reasons (such as placing an order for eyeglasses or contact lenses, or to bill a third party insurance), we generally will not ask you for written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
• disclosures to governmental authorities as required by law if we reasonably believe that someone may be a victim of abuse, neglect or domestic violence;
• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• when a state or federal law requires that certain health information be reported for a specific purpose;
• disclosures for purposes of health related research;
• disclosures to prevent a serious threat to your health or the health or safety of another person or the public;
• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
• disclosures relating to worker's compensation programs;
• uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• disclosures to business associates who perform health care operations for us (for example: outsourced third-party billing agencies) who have agreed to respect the privacy of your information;

PERSONS INVOLVED IN YOUR CARE

Unless you inform us otherwise, we will also share relevant information about your care with family or friends who accompany you into the examination room or who appear to us to be helping you with your eye care decisions. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment, disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences in allowing a person to pick up eyeglasses, contact lenses, prescriptions, or other forms of health information on your behalf.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information beyond those outlined in this Notice unless you sign a written authorization form, the content of which is determined by federal law. Sometimes, we may initiate the authorization process. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the disclosure. If you do sign one, you may revoke it at any time unless we have already acted upon it. Revocations must be in writing and should be sent to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:

• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address shown at the beginning of this Notice.
• ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost incurred on us for doing so. If you want to ask for confidential communications, send a written request to the office contact person at the address shown at the beginning of this Notice.
• ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You must make your request in writing to obtain access to your records. You will be charged a reasonable cost-based fee for expenses such as copies, postage and staff time. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address shown at the beginning of this Notice.
• ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address shown at the beginning of this Notice.
• get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address shown at the beginning of this Notice.
• get additional paper copies of this Notice of Privacy Practices upon request. If you want additional paper copies, send a written request to the office contact person at the address shown at the beginning of this Notice, or you can obtain one without a written request by requesting one in person from our office during normal office hours at no charge.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our "Notice of Privacy Practices", we will post the new notice in our office, have copies available in our office, and post it on our Web site.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone with the office contact person.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.