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.
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
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 glasses, contact lenses, or eye medications and faxing
them to be filled; showing you low vision aids; referring you to another doctor or clinic
for eye care or low vision aids or services; or getting copies of your health information
from another professional that you may have seen before us. 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; and collecting unpaid amounts (either ourselves or through a collection agency
or attorney). "Health care operations" mean those administrative and managerial
functions that we have to do in order to run our office. Examples of how we use or
disclose your health information for health care operations are: financial or billing
audits; internal quality assurance; personnel decisions; participation in managed care
plans; defense of legal matters; business planning; notification of appointments through
the use of recall postcards or voice mail; notification by postcard of referral credit
through "Share the Care" program; and outside storage of our records.
We routinely use your health information inside our office for these purposes
without any special permission. If we need to disclose your health information outside
of our office for these reasons, we ask you for special written permission.
Jeanne F. Klopfenstein, O.D., F.A.A.O.
3246 Kimball Avenue
We will not make any other uses or disclosures of your health information unless
you sign a written "authorization form." The content of an "authorization form" is
determined by federal law. Sometimes, we may initiate the authorization process if the
use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea
for us to send your information to someone else. Typically, in this situation you will
give us a properly completed authorization form, or you can use one of ours.
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 use or disclosure.
If you do sign one, you may revoke it at any time unless we have already acted in
reliance upon it. Revocations must be in writing. Send them to the office contact
person named at the beginning of this Notice.
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.
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, fax, or email shown at the beginning of this Notice. If
you prefer, you can discuss your complaint in person or by phone.
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.