"Vision is more than 20/20 eyesight"

Purpose:
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.

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This notice takes effect on April 14, 2003 and remains in effect until we replace it.

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1. OUR PLEDGE REGARDING MEDICAL INFORMATION
Protected health information is information about you including demographics that may identify you and That relates to your past, present or future physical or mental health care and related health care services We are committed to protecting your information We create a record of the care and services you receive at our facility We keep this record to provide you with quality care and to comply with legal requirements This notice will tell you about the ways we may use and share medical information about you, We also inform you of your rights and outline certain duties we have regarding the use and disclosure of medical information.

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2. OUR LEGAL DUTY

Law Requires Us to:

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1. Protect your health information

2. Give you this notice describing our legal duties, privacy practices and your rights regarding your medical information

3. Abide by the terms of privacy practices now in effect

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We Have the Right to:

1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law

2. Make the changes in our privacy practices and the new terms of our notice effective for all medical! Information that we store including information previously created or received before the changes

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Notice of Change to Privacy Practices:

1. Before we make any important change in our privacy practices, we will change this notice and make the new notice available upon request

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3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
This section describes different ways that we use and disclose medical information Following are different kinds of uses or disclosures and their meaning not every use or disclosure will be listed however, we have listed examples of ways we are permitted to use and disclose medical information

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FOR TREATMENT:
We will use and disclose your protected health Information to provide coordinate, or manage your healthcare and any related services this includes the coordination or management of your health) care with a third party that has already obtained your permission to have access to your protected health information

Example: We would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will! also disclose protected health information to other physicians whom may be treating you when we have the necessary permission from you to disclose your protected health information For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information 10 diagnose or treat you

In addition, we may disclose your protected health Information from time-to-time to another physician or health care provider (e.g., nurses, technicians, medical students or healthcare providers) who, at The request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment your physician For example, we may disclose your protected health information to medical school students t that see patients al our office In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician We may also call you by name in the waiting room when your physician is ready to see you We may use or disclose your protected health information, as necessary to contact you to remind you of your appointment

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FOR PAYMENT:
Your protected health information will be used and disclosed, as needed, to obtain payments for health care services.

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Example: You have surgery.

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• We may need to give your health insurance plan information about surgery you received, so that your health plan will pay us or repay you for any surgery that you paid for.

• We may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for the treatment

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FOR HEALTH CARE OPERATIONS:

We may use and disclose your medical information for our health care operations This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting accreditation, certificates, licenses and credentials we need to serve you We will share your protected health information with third party "business associates" that performs various activities (e.g., billing transcription services) for the practice Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information we will have a written contract that contains terms that will protect the privacy of your protected health information.

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USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATION

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ADDITIONAL USES AND DISCLOSURES:

Other uses and disclosures of protected health information will only be made with your written authorization unless otherwise permitted or required by law you may revoke this authorization in writing at any time the exception to this revocation is that your physician has taken an action in reliance on the authorization. In addition to using and disclosing your medical information for treatment, payment and health care operations we may use and disclose medical information for the following purposes

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Notification:
Medical information to notify or help notify

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• A family member

• Your personal representative

• Another person responsible for your care

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We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. n case of emergency and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We with also use our professional judgment to make decisions in your best interest: about allowing someone to pick up medicine, medicinal supplies, x-ray or medical information for you.

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OTHER PERMITTED AND REQUIRED DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT.

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Appointment Reminders:
We may use your medical information to contact you to provide appointment reminders

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Communication Barriers:
We may use and disclose your protected health information If your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclose under the circumstances

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Facilities/Patient Directories:
We may use the following medical information in our facilities directories: your name, your location in our facility your general medical condition We will disclose this information to members of the clergy or except for religious affiliation to other persons We will provide you with an opportunity to restrict or prohibit some or all disclosures for facility directories unless emergency circumstances prevent your opportunity to object

Fundraising:
We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications.

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Marketing Health Related Services:
We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you we may disclose your medical information to a business associate to assist us in these activities.

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OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT.

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Military Activity and National Security:
When the 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 Veterans Affairs of your eligibility for benefits or (3) to foreign military authority if you area member of that foreign military 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 legally authorized 

 

Government Functions (Specialized):
Subject to certain requirements, we may disclose or use health information for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits

Court Orders and Judicial and Administrative Proceedings:
We may disclose medical information In response to a court or administrative order, subpoena, discovery request, or other lawful process under certain circumstances, Under limited circumstances, such as a court order warrant, or grand jury subpoena, we may share your medical information with law enforcement officials We may share limited information with a law enforcement official to concerning the medical information of a suspect, fugitive material witness, crime victim or missing person We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances 

Public Health:
As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease injury or disability, including child abuse or neglect we may also disclose
your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements to track products, or to conduct activities required by the Food and Drug Administration

Communicable Diseases:
We may when authorized by law to do so notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition

Victims Of Abuse, Neglect. Or Domestic Abuse:
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 entry 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

Workers Compensation:
Your protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established programs

Health Oversight Activities:
We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits civil, administrative, or criminal investigations or proceedings, inspections licenses disciplinary actions, or other authorized activities.

Law Enforcement:
Under certain circumstances we may disclose health information to law enforcement officials These circum- stances include reporting required by certain laws (such as the reporting of certain types of wounds) pursuant to certain subpoenas or court orders reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies

Inmates:
We may use or 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

Research in Limited Circumstances:
We may disclose your protected health information in limited circumstances 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

Disaster Relief:
We may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in dlsas1er relief efforts

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4. YOUR PATIENT RIGHTS

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You Have a Right to:

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1. Inspect or get copies of your medical information you may request that we provide copies in a format other than photocopies We will use the format you request unless it is not practical for us to do so You must make your request in willing You may get the form to request access by contacting the practice administrator listed at the end of this notice You may also request access by sending a letter to the contact person listed at the end of this notice.
   If you request copies, we will charge you for each page, and postage if you want the copies mailed to you. Contact us for a full explanation of our fee structure.

2. You have the right to receive an accounting of certain disclosures we have made It 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 disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the light to receive specific information regarding these disclosures that occurred after Apri114, 2003. You may request a shorter timeframe. The right to receive this Information is subject to certain exceptions, restrictions and limitations

3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).

4. Request to receive confidential communications from us by alternative means or to alternative locations. Your request must be made in writing to the contact person listed at the end of this notice.

5. Request that we amend your protected health information. In certain cases we may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the Information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others including people you name, of the change and to include the changes In any future sharing of that information.

6. You have a right to refuse a copy of the Notice of Privacy Practices. Your treatment will not be conditioned on your refusal unless it is for the purpose of creating health information or research related treatment.

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FOR ANY QUESTIONS AND COMPLAINTS ABOUT THIS NOTICE, PLEASE CONTACT us:

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The Visual Performance Center
P.O. Box 4482
Huntsville, Alabama 35815
Phone: (256) 880-0133

visualpc@visualperformancecenter.com

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If you believe that your privacy rights have been violated, contact the practice administrator named above. You may also submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.