PRIVACY PRACTICES

Privacy Protection Policy

Our Commitment to You

At Palm Coast Eye Center, we recognize the sensitive nature of your personal health information, and take every precaution to protect your privacy. When you entrust us with this information, you can be certain it will be used only within our strict guidelines.

We've prepared this brochure to explain what types of information we collect, and under what circumstances we may share it.

We hope you will read through all the details of Palm Coast Eye Center's official position on privacy. Importantly, we want you to understand that Palm Coast Eye Center uses information responsibly and in order to:

• Provide you with the healthcare services you've requested
• File your healthcare claim with your insurance company
• Make your appointment at the Palm Coast Eye Center more convenient and efficient for you

In no case do we provide account or personal health information to any other companies for the purpose of independent telemarketing or direct mail marketing of any types of products or services.

Any questions about your privacy rights, please e-mail the Palm Coast Privacy officer at: ramona@palmcoasteyecenter.com

The Kinds of Information We Collect

When you register at the Palm Coast Eye Center, we ask you to provide us with information in order to accurately file your insurance claim. The following information is requested:

• Name and address
• Telephone number, home and work
• Social Security Number
• E-Mail address
• Birthdate
• Sex
• Marital Status
• Guarantor demographic information
• Insurance carrier name and address
• Insurance ID and group number
• Scheduled Procedure
• Patients' history and physical
• Picture Identification

How We Use This Information

Most of the information we collect is used for only one purpose - to help us deliver the healthcare services you've requested, accurately and efficiently.

Who Has Access To This Information?

Within Palm Coast Eye Centers:

Palm Coast Eye Center employees are permitted access to the information they need to perform their jobs on your behalf. We maintain strict internal policies against unauthorized disclosure or use of personal health information by employees.

Outside service providers:

We have arrangements with companies whose expertise is essential for our services to operate properly. For example, we work with companies that perform surgical, pathology, laboratory, pharmacy, management, and medical transcription services. In the future, other companies may prepare our financial statements, enable on-line claims submission and make banking transactions. These firms would perform their functions at Palm Coast Eye Center's directions and, as permitted by law, we would share patient information necessary to perform these functions with them. As with all our business partners, these companies will be required to safeguard your information and use it only for authorized purposes.

Courts and government bodies:

Certain federal and state laws may require us to share information about you. For example, if you are involved in a legal matter with a third party, we may be ordered to provide information to court or the other party. In these circumstances, only the specific information required by law, subpoena, or court order will be shared.

New Patient Rights Are On the Way

For the first time ever, the federal government passed comprehensive privacy regulations for health information. This new federal regulation establishes standards for most healthcare providers and payers in the protection of health information and established new patient rights.

The new privacy regulations are part of the Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996. The privacy rules became effective in April 2001, and gave healthcare providers two years to comply.

At the Palm Coast Eye Center, we have always protected our patients' privacy and the new rule amounts to informing our patients about the HIPAA regulations.

What Rights Do Patients Have?

Patients at the Palm Coast Eye Center have the rights to:

• Access or inspect their medical record
• Obtain a copy of their medical record
• Access and copying for as long as information is retained (seven years for adults and seven years after minors become adults)
• Request an amendment to their medical record. Request a list of when and where their confidential information was released within the past six years (may not include information released for care and treatment purposes, for payment, or when used for internal quality assurance purposes)
• Request an organization to restrict the use and disclosure of their confidential information (can request restriction in use of information for treatment, payment, or healthcare operation purposes, however, we can choose if we will honor the request)
• Request to receive communication by alternative means or locations (such as leaving messages at work instead of at home

File a complaint to the following if you believe your privacy rights were violated:

1. The Palm Coast Eye Center Privacy Officer
2. The Secretary of the Department of Health and Human Services,

Mike Leavitt
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202)619-0257
Toll Free: 1-877-696-6775
E-mail: HHS.Mail@hhs.gov

Receive a notice of Palm Coast Eye Center privacy practices (in office brochure & website)

The Palm Coast Eye Center is committed to Protecting Your Privacy

The health information professionals at The Palm Coast Eye Center have been trained to manage many of the systems required by HIPAA. Professionally, we are bound by a code of ethics to promote and protect the confidentiality and security of your medical records and health information. Our goal is to have patients' trust that their medical records and confidential information will remain private. Our health information professionals are committed to maintaining privacy and quality of care.