A Comprehensive Ophthalmology Medical Group, Inc.



APRIL 14, 2003

1. Purpose of this Notice. We consider any information that concerns your health, health care or payment for that care to be confidential and protected information. This Notice describes our privacy practices, specifically how we use and disclose your medical information and what rights you have with respect to this information. This information includes your name, address, and other identifying data, and information on your health or the health services that have been or may be furnished to you. We require all of our employees, staff, volunteers and independent contractors to comply with these privacy practices. We are required by federal law to obtain an acknowledgment from you that you received this Notice. Please sign the attached Acknowledgment Form and return it to South Coast Eye Care Centers. Please feel free to contact our office manager to discuss this notice or to request additional information regarding any of our privacy practices.

2. The Use and Disclosure of Medical Information for Treatment, Payment and Health Care Operations. By law we are allowed to use and disclose your medical information for most purposes related to your medical treatment ("Treatment"), the payment for your medical treatment ("Payment"), and our health care operations or the operations of other covered entities to which we disclose your medical information ("Operations").
Treatment means the provision, coordination or management of health care and related services by or involving one or more health care providers, such as the coordination of consultations and referrals. For example, we can share most medical information regarding your health condition with another provider as part of a consultation. We may also contact you to remind you to make or that you already made an appointment; to notify you regarding treatment alternatives or other health-related benefits and services that may be of interest to you. We will leave a message regarding your appointment type, date and time on your answering machine if you are not at home. We will fax and or mail your medical information to our other facility, consulting physicians, your Primary Care Physician, insurance companies or other health care providers if necessary for your medical treatment/payment. Please note that by law, certain medical information, such as psychotherapy notes, generally may not be used or shared even when it is related to your treatment, unless we obtain an Authorization from you to use or release that information.
Payment means activities related to obtaining reimbursement from HMOs, insurers or other payers for services provided to you. Payment can also cover activities to determine your eligibility for services with your insurer, coordination of benefits with other insurers, billing, claims management, collection, medical necessity review activities, utilization review activities, and disclosure to consumer reporting agencies. For example, we can disclose to your health plan medical information that is required by the plan to determine whether the services we have provided to you are medically necessary. We can also disclose to your health plan a list of the services that you obtained from us so that we can be paid by the health plan for providing the services to you.
Operations cover a range of activities that are necessary for the business of health care providers, payers or clearinghouses (i.e., entities performing certain billing or payment functions). They may be performed by our employees or in some cases by third-party contractors. These operations include: quality assessment and improvement activities; peer review; credentialing and licensing; training programs; legal and financial services; business planning and development; management activities related to privacy practices; customer services; internal grievances; creating de-identified information for data aggregation or other purposes; fundraising; certain marketing activities; and due diligence activities. For example, we evaluate practitioner performance to ensure that they meet our quality standards. Engaging counsel to defend us in a legal action is another activity that is considered health care operations.

3. Authorizations for Other Uses and Disclosures of Your Medical Information. Unless a use or disclosure is permitted for treatment, payment or operations purposes under Section 2 of this Notice, or is permitted or required under Section 4 or 5 of this Notice, we must obtain a signed Authorization from you to use or disclose your medical information. We may also require an Authorization when using or disclosing certain highly protected information, such as substance abuse information. An Authorization is a written permission that specifically identifies the information that we will use or disclose, and when and how we will use or disclose it. You may revoke an Authorization at any time except to the extent that we have already used or disclosed your information in reliance on your Authorization.

4. Use and Disclosure of Medical Information Without Your Consent or Authorization. If You Don't Object Verbally. Under certain circumstances, we may use or disclose your medical information without an Authorization or other written permission from you if we give you the opportunity to agree or object verbally. These circumstances are as follows:
a. To a relative, friend or individual involved in your care. We may provide medical information about you to your relative or friend, or another individual involved in your care. We will attempt to seek, or, in some circumstances, using our professional judgment, will infer your permission to make this disclosure. If we are not able, for instance, because of your condition or because you are not immediately present, we will use our best judgment to determine whether you would want this information shared.
b. For disaster relief. We may use or disclose your medical information to an entity that assists in disaster relief efforts.

5. Use and Disclosure of Medical Information Without Your Consent or Opportunity to Agree or Object Verbally. In the following situations, we are permitted under law to use or disclose your medical information without obtaining your consent or authorization or allowing you to agree or object.
a. As required by law. Numerous state, federal, and local laws permit or require certain uses and disclosures of medical information. However, we may only use or disclose your medical information to the extent authorized by the law.
b. To business associates. We may disclose your medical information to our business associates who perform functions on our behalf if we first receive satisfactory assurance that the business associate will safeguard your information.
c. For public health activities. We may be asked or required by law to divulge medical information to a public health authority under the following circumstances:
i. to report a birth, death, disease or injury, as required by law;
ii. as part of a public health investigation;
iii. to report child or adult abuse or neglect, or domestic violence, as authorized by law;
iv. to report adverse events (such as product defects), to track products or assist in product recalls or repairs or replacements, or to conduct post-marketing surveillance, as required by the Food and Drug Administration;
v. to notify a person about exposure to a possible communicable disease, as required by law; and
vi. to your employer if, we are conducting an evaluation relating to the medical surveillance of the employer’s workplace or to evaluate whether you have a work related injury and only to the extent that the disclosure concerns such surveillance or injury.
d. For health oversight activities. Health oversight activities include audits, government investigations, inspections, disciplinary proceedings, and other administrative and judicial actions undertaken by the government (or their contractors) by law to oversee the health care system. We may be asked or required to share medical information with a health oversight agency for these activities.
e. To report victims of abuse, neglect or domestic violence. If we believe that you are a victim of abuse, neglect or domestic violence, we may report this information to a governmental authority, social service or protective services agency if we believe the disclosure is necessary to prevent serious harm to you or another individual, if you cannot agree, or if the disclosure is required by law. If we make such a disclosure, you will be notified promptly unless notification to you would place you at serious risk of harm or is otherwise not in your best interest.
f. For judicial and administrative proceedings. We may disclose medical information as required by a court or administrative order, or in some instances pursuant to a subpoena, discovery request or other legal process.
g. To law enforcement. Police and other law enforcement may seek medical information from us. We may release this information to law enforcement under limited circumstances, for example, when the request is accompanied by a warrant, subpoena, court order, or similar legal process, or when law enforcement needs specific information to locate a suspect or stop a crime.
h. To coroners, medical examiners and funeral directors. We may release information regarding a person who has died as required by law or in order to facilitate funereal activities.
i. For organ, eye, and tissue donation. We may provide medical information to organ procurement organizations and similar entities in order to facilitate organ, eye and tissue donation and transplantation.
j. For research purposes. We may be approached by researchers to provide medical information for research purposes, such as tracking a particular disease. We may provide medical information to a researcher who has obtained a special waiver that allows the researcher to collect patients' medical information without first obtaining the patients' permission. These waivers must be obtained from a committee established under federal law to oversee medical research. The researcher must demonstrate to the committee that the information is necessary to the research and poses a minimal risk of an inappropriate use or disclosure.
k. To avert a serious threat to health and safety. We may use or disclose your medical information to avert a serious and imminent threat to the health and safety of an individual or the public.
l. For military and other specialized government functions.
i. Armed Forces. We may disclose your medical information if you are a member of the Armed Forces, as deemed necessary by military command authorities, and if you are foreign military personnel, to your appropriate authority.
ii. National Security and Intelligence. We may disclose your medical information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities, and for protective services to the President and other heads of state or authorized persons.
iii. Correctional Institutions. If you are an inmate, we may disclose your medical information to correctional institutions or law enforcement personnel having lawful custody of you for administration and maintenance of the safety, security and good order of the correctional institution; of identification necessary to provide health care to you, or to protect you, other inmates, employees and officers of the institution, individuals participating in your transportation, or law enforcement at the institution.
iv. Other Government Agencies. We may disclose your medical information to other government entities that administer public benefits to populations similar to the population that we serve, if necessary to coordinate the functions of the programs.
m. For workers' compensation. We may share information regarding work-related illnesses and injuries in order to comply with workers’ compensation laws.
n. Other permitted disclosures. We may disclose your medical information as required or permitted by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act, as amended and interpreted from time to time.

6. Individual Rights. You have the following rights with respect to your medical information:
a. Restrictions. You have the right to request in writing to us to restrict how we use and disclose your medical information. We do not have to agree to the restrictions that you request. If we do agree to the restrictions that you request, we must comply with the restrictions, except in emergency circumstances. We also have the right to ask you to revoke a restriction. Please contact our office manager to request a restriction.
b. Confidential Communications. You have the right to request in writing that we restrict the way in which we communicate information regarding your health, health care services, or payment. For example, you may ask that we communicate with you only at your home, not at your workplace. We will use reasonable efforts to accommodate your request. Please contact our office manager to obtain a form to make this request.
c. Access. You have the right to inspect and copy most of your medical information maintained by us. Normally, we will provide you with access within 30 days of your request. We may charge a reasonable copying fee. In certain limited instances, we may deny you access, for example, when the request is for psychotherapy notes. You have the right to a review of a denial of access to your medical information. Any request to inspect and copy medical information should be made to our office manager.
d. Amendment. You have the right to request that we amend your written medical information. For instance, you can request that we correct an incorrect surgery date in your records. We will generally amend your information within 60 days of your request, and will notify you when we have amended your information. We can deny your request in certain circumstances, such as when we believe that your information is accurate and complete. You can file a statement of disagreement to a denial of your request for amendment, to which we may file a rebuttal. Please direct any request to amend your medical information to our office manager.
e. Accounting. You have the right to request an accounting from us of certain disclosures made by us during the 6 years prior to your request, but no earlier than April 14, 2003. We will generally provide you with your accounting within 60 days of your request. Your request will be filled at no cost to you once every 12 months. For additional accountings, we will notify you in advance of the cost and give you an opportunity to continue or withdraw your request. These disclosures do not include those made for purposes of Treatment, Payment or Operations, those made pursuant to a signed Authorization, or for our facility directory or other disclosures described in Section 2 of this Notice. Please forward any accounting request to our office manager.
f. Paper Notice. If you have obtained this Notice electronically, you may obtain a paper copy by contacting our office manager or any staff member.
g. Complaints. If you believe that any of your rights with respect to your medical information have been violated by us or by our employees or agents, you may file a complaint with us and/or to the Secretary of the U.S. Department of Health and Human Services. Please contact our office manager for a complaint form. Under no circumstances will we take any retaliation against you for filing a complaint.

7. Our Duties. We are required by law to maintain the privacy of your medical information and to provide you with this Notice of our legal duties and privacy practices with respect to your medical information. We must comply with the Notice currently in effect.

We reserve the right to revise this Notice and will revise the Notice if we materially change any use, disclosure, individual right or legal duty or other privacy practice stated in this Notice. If we revise a Notice, copies will be available by asking our office manager or any staff member. We reserve the right to change our privacy practices retroactively with respect to information that we created or received prior to issuing a revised Notice.