Hippa Privacy
Physicians are responsible for ensuring that practice visitors and observers – such as students or medical device vendor representatives, understand the practice’s obligations regarding patient privacy. For any visitor who is not either a practice employee or business associate, it is essential for purpose of HIPAA compliance that patients are given the choice whether to allow the visitor to observe their care. Doctors have an ethical obligation as well to grant the patient’s discretion regarding the presence any non-necessary personnel present during the delivery of care.
Notice of Privacy Practices
Effective Date: 09/01/2018
Clinic Name: The Eye Care Center, Ltd
Address: 8525 S Harlem Avenue, Burbank, IL 60459
Phone: 708.599.0050
Fax: 708.599.1099
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.
Your Rights
- Get an electronic or paper copy of your medical record.
- Ask us to correct your medical record.
- Request confidential communications.
- Ask us to limit what we use or share.
- Get a list of those with whom we’ve shared your information.
- Get a copy of this privacy notice.
- Choose someone to act for you (e.g., legal guardian or power of attorney).
- File a complaint if you feel your rights are violated.
Your Choices
You have choices about how we share your information in situations like:
- Sharing with family and friends involved in your care.
- Inclusion in a hospital directory.
- Disaster relief efforts.
We never share your information without written permission for:
- Marketing purposes
- Sale of your information
- Fundraising (you may opt out)
Our Uses and Disclosures
We typically use or share your health information to:
- Treat you
- Run our organization
- Bill for your services
We may also share your information to support public health and safety, research, comply with the law, respond to organ donation requests, work with medical examiners or funeral directors, and more.
Our Responsibilities
- Maintain the privacy and security of your protected health information.
- Notify you if a breach occurs.
- Follow the duties and privacy practices described in this notice.
- Not use or share your information other than as described here unless you provide written permission.
- Update you if this notice changes in the future.
Appointment Reminders
We may contact you by phone or mail to remind you of appointments or inform you about treatments or services.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services.
For More Information
Contact our office at the number above if you have any questions about this notice or want more information.
Acknowledgement of Receipt
I acknowledge that I received a copy of the Notice of Privacy Practices.
Patient Name: _________________________________________
Signature: __________________________ Date: ________________
