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OMNI EYE SERVICES

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL AND OPTOMETRIC INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Omni Eye Services in compliance with the protected health information regulations issued by the Department of Health and Humans Services and in accordance with the (HIPAA) the Health Insurance Portability and Accountability Act provides this notice for your information. We are required by law to protect your health information and ensure that is it kept private, provide you with our Notice of Privacy Practices and your legal rights with respect to (PHI) protected health information, and abide by the conditions of the Notice that is currently in effect. We are committed to protecting all of the records of your care at Omni Eye Services.

USES AND DISCLOSURES

Here are some examples of how we might have to use or disclose your health information:

1) The doctors or staff of Omni Eye Services may have to disclose your health information including all of your clinical records to another health care provider, doctors, nurses or other personnel who are involved in you health care, hospital, or ambulatory surgery center if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition. We may schedule appointments with other health care providers and phone or fax prescriptions for medications to your pharmacy and we may request and receive information from other health care providers by mail or fax.

2) Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services. We will verify benefit enrollment, and or eligibility; giving information about treatment you are going to receive to your health plan to determine insurance coverage; preparing and sending bills or claims by means of paper or electronically and collecting unpaid amounts through either ourselves, a collection agency or attorney.

3) Your doctors and members of the staff may need to use your health information, examination and treatment records and your billing records for quality control purposes other administrative purposes to efficiently run our practice.

4) Your doctors and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health information that may be of interest to you. 164.520 (b)(1)(iii)(A). If you are not at home to receive an appointment reminder, a message will be left on your answering machine or a message will be left with family at your home phone number.

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at anytime.

OUR PRIVACY PLEDGE
The doctors and staff of Omni Eye Services have and always will respect your privacy. Other that the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.

PERMITTED USES AND DISCLOSURES WITHOUT YOUR CONSENT OR AUTHORIZATION
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:

1) We are permitted to use or disclose your health information if we are providing health care services to you based on the orders of another health care provider.

2) We are permitted to use or disclose your health information if we provide health care services to you as an inmate.

3) We are permitted to use or disclose your health information if we provide health care services to you in an emergency.

4) We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.

5) We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

6) We are permitted to use or disclose your health information When State or Federal law mandates it.

7) We are permitted to use or disclose your health information for public health purposes to prevent the spread of contagious disease, serious threat to public health or safety or notices to/from the Federal Food and Drug Administration regarding medications or medical and surgical devices.

8) We are permitted to use or disclose your health information regarding suspected victims of abuse, neglect or domestic violence.

9) We are permitted to use or disclose your health information to a medical examiner, funeral director or organizations that handle organ/tissue donations.

10) We are permitted to use or disclose your health information relating to worker's compensation programs.

11) We are permitted to use or disclose your health information regarding Incidental disclosures that are an unavoidable by-product of permitted use/disclosures.

12) We are permitted to use or disclose your health information to "business associates" who perform health care operations for Omni Eye Services and who commit to respect the privacy of your health care information.

We will share relevant information about your eye health care with your immediate family or other caregivers that are involved in your care.

We may use and disclose health information to contact you to remind you of scheduled appointments or that it is time or further care of services. We may notify you of other treatments or services available at our facility that might be of benefit to you. This contact may be by phone or in writing and may involve leaving a message on an answering machine, which could possibly be received by others.

Other than the circumstances described in the preceding examples, or the laws that apply to us and other use or disclosure of your health information will only be made with your written consent, unless those uses can be reasonably inferred from the intended uses above.

PATIENTS RIGHTS

You have the following rights regarding health information that Omni Eye Services maintains about you:

1) You have the right to inspect and receive a copy of your health information that may be used to make decisions about your care. This includes your own medical and billing records. Upon proof of an appropriate legal relationship, records of others to you or under your care (guardian or custodial) may be disclosed.

2) You have the right to inspect and receive a copy of your medical records; you must submit your request in writing to Omni Eye Services. We will respond to the request within 30 days. By law, we may have one 30-day extension of the time for us to give you access or photocopies if we send you written notice of the needed extension. We have the right to charge a fee for the costs of copying, and mailing.

Under very limited circumstances we may deny your request to inspect and copy. If we deny your request we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available.

You have the right to revoke your authorization to us at any time: however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:

1) If we have already released your health information before we receive your request your authorization 164.508(b)(5)(i).

2) If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. If you wish to revoke your authorization please write to us at:

Omni Eye Services
1203 Ridgeway Road #201
Memphis, TN 38119

RIGHT TO AMEND
If you believe that the health information we have about you in your record is incorrect or incomplete You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.

To request an amendment please submit your request in writing, along with your intended amendment and a reason that supports your request to amend. The amendment must be dated, signed by you, and notarized. If we agree, we will amend the information within 60 days of the written request. We will send the corrected information to persons who we know have the incorrect information and to others that your specify.

We may deny your request to amend if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend information that:

1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment

2) is not a part of the health information kept by or for Omni Eye Services

3) is not a part of the information which you would be permitted to inspect and copy; or is inaccurate and incomplete.

If your request for an amendment is denied you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we feel necessary. We will not amend health information falsely.

By law, we can have one 30-day extension of time to consider a request for an amendment if we notify you in writing of the extension.

RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an accounting of disclosures we have made of your health information for the last 6 years before the date of your request. The accounting will include all disclosures except:

1) those disclosures required for your treatment, to obtain payment for your services or to run our practice

2) those disclosures made to you

3) those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved with your care

4) those disclosures for national security or intelligence purposes

5) those disclosures made to correctional officers or law enforcement officers

6) those disclosures that were made prior to the effective date of the HIPAA privacy laws April 14, 2003

We will provide the first accounting within any 12 month period without charge. There is a fee for any additional requests during the next 12 months. When you make a request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request. The fee must be paid in advance. We will respond to your request within 60 days of receiving your written notice to the Privacy Officer at Omni Eye Services. By law, we can have one 30-day extension of time if we notify you of the extension in writing.

YOUR RIGHT TO LIMIT USES OR DISCLOSURES

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations, as well as the health information we disclose about you to someone who is involved in your care or the payment for your care, this could be like a family member or friend. An example of this would be you asking us not to disclose information regarding a particular treatment you received.

To request a restriction, please submit a written request to the Privacy Officer at Omni Eye Services. We do not have to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

YOUR RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATION REGARDING YOUR HEALTH INFORMATION

You have the right to request that we communicate with you about medical matters in a specific way or at a specific location. For example, you may ask that we contact you at work instead of your home. Omni Eye Services will grant reasonable requests for confidential communications at alternative locations or by alternative means only if the request is submitted in writing to the Privacy Officer. The written request must include a mailing address where you will receive bills for services rendered by Omni Eye Services and related correspondence regarding payment for services. We reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

YOUR RIGHT TO A PAPER COPY OF THIS NOTICE

You have the right to a paper copy of this notice. You may ask us to give you a copy at any time.

CHANGES TO OUR PRIVACY NOTICE

We reserve the right to change this notice at any time, as allowed by law. We reserve the right to make the revised or changed notice effective for information we already have about you as well as any other information we may receive from you in the future. We will post a copy of the current notice, including the effective date in our office as well as our web site WWW.OMNIEYESERVICESOFMEMPHIS.COM
Copies available to you.

RE-DISCLOSURE

Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information any may no longer be protected by the federal privacy rules.

YOUR RIGHT TO COMPLAIN

You may complain to the Privacy Officer of Omni Eye Services or to the Secretary of Health and Human Services if you feel that your privacy rights have been violated.

While you may make an oral complaint at any time, written comments should be addressed to the above. All complaints shall be investigated. We respect your right to file a complaint and will not take any action against you if you file a complaint.