The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal regulation requiring that all medical records and other personally identifiable health information used or disclosed to our practice in any form be kept properly confidential.

As required by “HIPAA” this notice describes our legal responsibilities with regards to your protected health information (PHI), how this information may be used and disclosed by us, your rights with regards to your health information, as well as contact information for your questions or objections.

I. Our Legal Responsibilities Regarding Your Protected Health Information
We are legally responsible for insuring that all protected health information identifying you is kept private. We are also held legally accountable for providing you with this notice and for following its terms and conditions. We reserve the right to change any of the terms of this notice at any time within HIPAA federal guidelines. These changes will apply to all health information already held by our office.

II. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by the staff at Urban Eye MD Associates

for the following purposes:

1. Treatment: Treatment includes the provision, coordination, or management of health care and related services by one or more health care providers. For example, your PHI may be provided to a physician from whom you have been referred to ensure that the physician has the necessary information to diagnose, treat you, or coordinate your care.

2. Payment: Payment includes obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. For example, a bill for your visit would be sent to your insurance company for payment.

3. Health care operations: Health Care Operations are best described as the business aspects of running our practice, and include but are not limited to assessment activities, auditing functions, customer service, cost-management operations, and business planning activities. For example we may use or disclose your PHI to your insurance company to evaluate the quality of care you received from us.

4. Health related services: We may use your information to contact you about health related services including appointment reminders, lab results, and possible treatment options.

5. When we are unable to obtain your authorization: We may use or disclose your information in situations when you are unable to provide us with your permission. For example if you are unconscious and in need of emergency treatment, and we believe you would consent to the use and disclosure of your PHI, we will use and disclose this information.

6. Disclosures required by law: We will use and disclose your PHI when we are required to do so by federal, state, or local law.

7. Public health risks: We may disclose information to public health authorities whose duties include collecting data with regards to the prevention and control of disease, injury, or disability.

8. Serious threats to health or safety: We may disclose your PHI when necessary to prevent or reduce a serious threat to your safety and health, or to the safety and health of another individual or to the public. This information may only be disclosed to a person or organization able to help prevent the threat.

9. Government purposes: We may disclose information of members of the United States military, or of veterans of the United States military. Additionally, we may disclose your information to federal officials for intelligence and national security activities authorized by law including the protection of the President of the United States.

10. Worker’s compensation purposes: We may disclose your health information for the purpose of worker’s compensation or other related activities.

11. Inmates: We may disclose your PHI if you are an inmate or under the custody of a law enforcement official.

12. Disclosure to family, or others: We will use our best judgment in disclosing PHI or payment information to a family member, spouse or other person involved in your care, unless you object. Retroactive authorization may be obtained in emergency situations.

III. Your Rights Regarding Your Protected Health Information
You have the following rights with regards to your PHI:

1. The right to request restrictions on uses and disclosures of this information: You may request restrictions related to disclosures of health information to family members, other relatives, spouses, personal care-takers, or any other person identified by you. Additionally, you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment, or health
operations. We are not however, legally required to accept your request. If we agree to the restriction then we must abide by it unless you agree in writing to remove it.

2. The right to receive confidential communications of your PHI: You may request to receive communications of your health information from us by alternative means or at alternative locations. For example you may request that we contact you with information at home rather than at work.

3. The right to inspect and copy your PHI: If you wish to inspect or copy your PHI, a request must be made in writing to the HIPAA compliance officer. An administrative fee to cover copying expenses may be charged to you.

4. The right to amend your health information: If you believe your health information is incorrect or incomplete, you may request that this information be amended at any time. This request must be made in writing to the HIPAA compliance officer.

6. The right to receive an accounting of disclosures of your PHI: An accounting of disclosures is a list of non-routine disclosures our practice has made of your PHI. This request must be made in writing to the HIPAA compliance officer and may be dated, at most, six years from the date of disclosure.

7. The right to a paper copy: You may ask us to give you a paper copy of this notice at any time.

8. The right to file a complaint: If you feel your privacy has been violated by our practice you may file a complaint at any time. In order to do so you must contact the HIPAA compliance officer in writing.

IV. Contact Information
If you have any questions about or objections to this form please ask to speak with our HIPAA compliance officer, at: Phone: (617) 262-6300 or (617) 638-8119