Effective: January 11, 2005
Notice of Privacy Practice
This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. Please review it carefully.
Drs. Perez and Chiang have the legal obligation to keep health information that identifies you private. This law obligates us to give you notice of our privacy practices.
Generally, we can only use your health information in our office or disclose it outside of our office, without you written permission, only for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written release authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.
Uses or Disclosures of Health Information
Examples of how we use information for treatment purposes:
When we schedule an appointment for you.
When our technician or doctor tests your eyes.
When the doctor prescribes glasses or contact lenses.
When the doctor prescribes medication.
When our staff helps you select and order glasses or contact lenses
When we show you low vision aids.
When we demonstrate vision therapy procedures
We may disclose your health information outside of our office for treatment purposes, for example:
If we refer you to another doctor or clinic for eye care or low vision aids or services.
If we send a prescription for glasses or contacts to another professional to be filled.
When we provide a prescription for medication to a pharmacist.
When we phone to inform you that your glasses or contact lenses are ready to be picked up.
We may ask for copies of your health information (by telephone, mail, fax, e-mail) from another professional that you have seen before.
We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:
When our staff asks you about your heath or vision care plans, or about other sources of payments for our services.
When we prepare and send bills or claims to you or your health or vision plan by mail, FAX or computer.
When we process payment by credit card.
When we attempt to collect unpaid amounts, ourselves or through a collection agency or attorney.
Health care operations refer to those administrative and managerial functions that we have to do in order to run our office. We use and disclose your health information for healthcare operations in a number of ways. For example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.
Unless you tell us otherwise:
We may also share relevant information about your care with your family or others who are involved with your eye care.
Our office policy operations may administer, demonstrate, and share vision therapy sessions in an environment with other patients in the same vision therapy room/exam room.
We may also share relevant information, as well as collaborate with other healthcare professionals for your welfare.
We may call to remind you of scheduled appointments. We may call or write to notify you of other treatments or services available at our office that might benefit you. Unless you tell us otherwise, we may mail you an appointment reminder on a postcard, and/or leave you a reminder messages on your machine or with someone who answers your phone if you are not available.
Uses & Disclosures without an Authorization
In some limited situations, the law allows or requires us to use or disclose your health information without your consent. Not all of these situations will apply to us: some may arise in our office at all. Such uses or disclosures are:
A State or federal law that mandates certain health information is reported for a specific purpose.
Public heath purposes, such as contagious diseases reporting, investigation or surveillance; and notices to and from the Food and Drug Administration regarding drugs or medical devises.
Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence.
Uses and disclosures for health oversight activities, such as for the licensing of doctors, audits by Medicare or Medicaid, or investigation of possible violations of healthcare laws.
Disclosures for judicial and administrative proceedings, such as in person to subpoenas or orders of the courts or administrative agencies.
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 occurred somewhere else.
Disclosure to a medical examiner to identify a deceased 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.
Uses or disclosures for health related research.
Uses and disclosures to prevent a serious threat to health or safety
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.
Disclosures relating to worker’s compensation programs.
Disclosures to business associate who perform healthcare operations for us and who agree to respect the privacy of your health information.
We will not make any other uses or disclosures of your health information unless you sign a written authorization form. You may choose not to sign such a form. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it.
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 healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you request.
Ask us to communicate with you in a confidential way, by phoning you at home rather than at work, by mailing health information to a different address, or by using e-mail to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost.
Ask to see or to get photocopies of your health information. By law, there are few limited situations in which we can deny access or copying. Primarily, however, you will be able to review or obtain a copy of your health information within 30 days of your request. You may need to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to obtain an impartial review of our denial if one is legally requires. By law, we may have one 30 day extension of the time for us to allow you access or photocopies provided we send you a written notice of the extension.
Ask us to amend your heath information if you feel that it is incorrect or incomplete. If we agree, we will amend the information within 60 days of your request and send the corrected information to persons who we know received 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 rebuttal is included in your health information, we will include it 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.
Obtain a list of disclosures that we have made of your health information within the past six years 9or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. If you would like more frequent lists, you must pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we may have one 30-day extension of time if we notify you of the extension in writing.
To make any of the above requests, send a written request to Lynn Cruz, the office contact person, by mail, fax or e-mail.
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 in compliance with and as followed 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 and have copies available in our office.
If you feel we have not properly respected your privacy of your health information, you are free to file a complaint with us or the U.S. Department of health and Human Services, office for Civil Rights. We will not retaliate against you if you file a complaint. To file a complaint with us, send your written complaint to Lynn Cruz, the office contact person, by mail, fax or e-mail. If you prefer we can discuss your complaint in person or by phone.
For More information
If you would like more information about our privacy practices, visit or call us.
Privacy Contact Officer: Dr. Perez