Advanced Family Eyecare of Hampton, LLC | Notice of Privacy Practices 11550 Tara Blvd | 770-707-0711 

Your Information. Your Rights. Our Responsibilities. 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 

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities  to help you.  

GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL  RECORD 

  • You can ask to see or get an electronic or paper copy of your  medical record and other health information we have about  you. Ask us how to do this.  
  • We will provide a copy or a summary of your health  information. We may charge a reasonable, cost-based fee. 

ASK US TO CORRECT YOUR MEDICAL RECORD 

  • You can ask us to correct health information about you that  you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in  writing within 60 days 

REQUEST CONFIDENTIAL COMMUNICATIONS 

  • You can ask us to contact you in a specific way (for example,  home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests. 

ASK US TO LIMIT WHAT WE USE OR SHARE 

  • You can ask us not to use or share certain health information  for treatment, payment, or our operations. We are not  required to agree to your request, and we may say “no” if it  would affect your care. 
  • If you pay for a service or health care item out-of-pocket in  full, you can ask us not to share that information for the  purpose of payment or our operations with your health  insurer. We will say “yes” unless a law requires us to share  that information. 

GET A LIST OF THOSE WITH WHOM WE’VE SHARED  INFORMATION 

  • You can ask for a list (accounting) of the times we’ve shared  your health information for six years prior to the date you ask, who we shared it with, and why. 
  • We will include all the disclosures except for those about  treatment, payment, and health care operations, and certain  other disclosures (such as any you asked us to make). We’ll  provide one accounting a year for free but will charge a  reasonable, cost-based fee if you ask for another one within  12 months. 

GET A COPY OF THIS PRIVACY NOTICE 

  • You can ask for a paper copy of this notice at any time, even  if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. 

CHOOSE SOMEONE TO ACT FOR YOU

  • If you have given someone medical power of attorney or if  someone is your legal guardian, that person can exercise  your rights and make choices about your health information. 
  • We will make sure the person has this authority and can act  for you before we take any action. 

Your Choices 

For certain health information, you can tell us your choices about  what we share. If you have a clear preference for how we share  your information in the situations described below, talk to us. Tell  us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others  involved in your care 
  • Share information in a disaster relief situation
  • Include your information in a hospital directory 

If you are not able to tell us your preference, for example if you are  unconscious, we may go ahead and share your information if we  believe it is in your best interest. We may also share your  information when needed to lessen a serious and imminent threat  to health or safety. 

In these cases we never share your information unless you give  us written permission: 

  • Marketing purposes 
  • Sale of your information 
  • Most sharing of psychotherapy notes 

In the case of fundraising: 

  • We may contact you for fundraising efforts, but you can tell  us not to contact you again. 
  • If we intend to use or disclose your substance use disorder  records (subject to 42 CFR Part 2) for fundraising purposes,  you have the right to elect not to receive such communications before we send them. 

Our Uses and Disclosures 

HOW DO WE TYPICALLY USE OR SHARE YOUR HEALTH  INFORMATION?  

We typically use or share your health information in the following  ways: 

TREAT YOU 

We can use your health information and share it with other  professionals who are treating you. 
Example: A doctor treating you for an injury asks another doctor  about your overall health condition. 

RUN OUR ORGANIZATION 

We can use and share your health information to run our practice,  improve your care, and contact you when necessary. Example: We use health information about you to manage your  treatment and services.  

BILL FOR YOUR SERVICES 

We can use and share your health information to bill and get  payment from health plans or other entities.
Example: We give information about you to your health insurance  plan so it will pay for your services.  

HOW ELSE CAN WE USE OR SHARE YOUR HEALTH  INFORMATION?  

We are allowed or required to share your information in other  ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in  the law before we can share your information for these purposes.  For more information see:  

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html 

STATE LAW AND SENSITIVE INFORMATION 

  • In some cases, state laws or other federal laws provide  greater privacy protections for specific types of “sensitive”  health information than the general HIPAA rules. This may  include information related to reproductive health (including  abortion and contraception), HIV/AIDS, mental health, or  genetic testing. When these stricter laws apply, we will follow  the law that provides you with the most protection before  sharing that information with others. 

SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)

  • We may use and disclose your substance use disorder  records subject to 42 CFR Part 2 for treatment, payment, and  health care operations as permitted by law. 

Prohibition on Use in Legal Proceedings:

  • We are prohibited  from using or disclosing your substance use disorder records subject to 42 CFR Part 2 in any civil, criminal, administrative,  or legislative proceedings against you without your specific  written consent or a court order. 

HELP WITH PUBLIC HEALTH AND SAFETY ISSUES We can share health information about you for certain situations  such as: 

  • Preventing disease 
  • Helping with product recalls 
  • Reporting adverse reactions to medications 
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or  safety 

DO RESEARCH 

We can use or share your information for health research. 

COMPLY WITH THE LAW 

We will share information about you if state or federal laws  require it, including with the Department of Health and Human  Services if it wants to see that we’re complying with federal  privacy law. 

RESPOND TO ORGAN AND TISSUE DONATION REQUESTS

We can share health information about you with organ  procurement organizations. 

WORK WITH A MEDICAL EXAMINER OR FUNERAL DIRECTOR

We can share health information with a coroner, medical  examiner, or funeral director when an individual dies. 

Advanced Family  
Eyecare of Hampton,  
LLC 

ADDRESS WORKERS’ COMPENSATION, LAW ENFORCEMENT,  AND OTHER GOVERNMENT REQUESTS 

We can use or share health information about you:

  • For workers’ compensation claims 
  • For law enforcement purposes or with a law enforcement  official 
  • With health oversight agencies for activities authorized by law 
  • For special government functions such as military, national  security, and presidential protective services 

RESPOND TO LAWSUITS AND LEGAL ACTIONS 

We can share health information about you in response to a court  or administrative order, or in response to a subpoena. 

Our Responsibilities 

  • We are required by law to maintain the privacy and security of your protected health information.  
  • We will let you know promptly if a breach occurs that may  have compromised the privacy or security of your  information. 
  • We must follow the duties and privacy practices described in  this notice and give you a copy of it.  
  • We will not use or share your information other than as  described here unless you tell us we can in writing. If you tell  us we can, you may change your mind at any time. Let us  know in writing if you change your mind.  

FOR MORE INFORMATION SEE:  

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html 

CHANGES TO THE TERMS OF THIS NOTICE 

We can change the terms of this notice, and the changes will  apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. 

FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE VIOLATED

You can complain if you feel we have violated your rights by  contacting the Privacy Officer at 770-707-0711. 

You can file a complaint with the U.S. Department of Health  and Human Services Office for Civil Rights by sending a letter  to 200 Independence Avenue, S.W., Washington, D.C. 20201,  calling 1-877-696-6775, or visiting  

www.hhs.gov/ocr/privacy/hipaa/complaints 

We will not retaliate against you for filing a complaint.