Hollister Vision Center

365 Sixth Street

Hollister, CA 95023

(831) 637-5536 or (831) 637-7601 (fax)

GENERAL RULE

We respect our legal obligation to keep
health information, that identifies you,
private. The law obligates us to give you
notice of our privacy practices.

Generally, we can only use your health
information in our office or disclose it
outside of our office, without your written
permission, for purposes of treatment,
payment or healthcare operations. In most
other situations, we will not use or
disclose your health information unless
you sign a written authorization form. In
some limited situations, the law allows or
requires us to disclose your health
information without written authorization.

USES OR DISCLOSURES OF HEALTH
INFORMATION

Examples of how we use information for
treatment purposes:

... When we set up an appointment for you.

... When our technician or doctor tests your
eyes.

... When the doctor prescribes glasses or
contact lenses.

... When the doctor prescribes medication.

... When our staff helps you select and
order glasses or contact lenses.

... When we show you low vision aids.

We may disclose your health information
outside of our office for treatment
purposes, for example:

... If we refer you to another doctor or clinic
for eye care or low vision aids or services.

... If we send a prescription for glasses or
contacts to another professional to be
filled.

... When we provide a prescription for
medication to a pharmacist.

... When we phone to let you know that
your glasses or contact lenses are ready
to be picked up.

Sometimes we may ask for copies of your
health information from another
professional that you may have seen
before.

We may use your health information within
our office or disclose your health
information outside of our office for
payment purposes.

Some examples are:

... When our staff asks you about health or
vision care plans that you may belong to,
or about other sources of payment for our
services.

... When we prepare bills to send to you or
your health or vision care plan.

... When we process payment by credit
card and when we try to collect unpaid
amounts due.

... When bills or claims for payment are
mailed, faxed, or sent by computer to you
or your health or vision plan.

... When we occasionally have to ask a
collection agency or attorney to help us
with unpaid amounts due.

We use and disclose your health
information for healthcare operations in a
number of ways. Health care operations
means those adminstrative and
managerial functions that we have to do in
order to run our office. We may use or
disclose your health information, for
example, for financial or billing audits, for
internal quality assurance, for personnel
decisions, to enable our doctors to
participate in managed care plans, for the
defense of legal matters, to develop
business plans, and for outside storage of
our records.

APPOINTMENT REMINDERS

We may call to remind you of scheduled
appointments. We may also call to notify
you of other treatments or services
available at our office that might help you.

USES & DISCLOSURES WITH AN
AUTHORIZATION
In some limited situations, the law allows
or requires us to use or disclose your
health information without your
permission. Not all of these situations will
apply to us; some may never happen at
our office at all. Such uses or disclosures
are:

... A state or federal law that mandates
certain health information be reported for a
specific purpose.

... Public health purposes, such as
contagious disease reporting,
investigation or surveillance; and notices
to and from the Food and Drug
Administration regarding drugs or medical
devices.

... Disclosures to governmental authorities
about victims of suspected abuse, neglect
or domestic violence.

... Uses and disclosures for health
oversight activities, such as the licensing
of doctors, audits by Medicare or Medicaid,
or investigation of possible violations of
healthcare laws.

...Disclosures for law enforcement
purposes, such as to provide information
about someone who is or is suspected to
be a victim of a crime; to provide
information about a crime at our office; or
to report a crime that happened
somewhere else.

... Disclosures for judicial and
administrative proceedings, such as in
response to subpoenas or orders of
courts or administrative agencies.

... Disclosure to a medical examiner to
identify a dead person or to determine the
cause of death; or to funeral directors to
aid in burial; or to organizations that
handle organ or tissue donations.

... Uses or disclosures for health related
research.

... Uses and disclosures to prevent a
serious threat to health or safety.

... Uses or disclosures for specialized
government functions.

... Disclosures relating to workers'
compensation programs.

... Disclosures to business associates
who perform healthcare operations for us
and who agree to keep your health
information private.

OTHER DISCLOSURES

We will not make any other uses or
disclosures of your health information
unless you sign a written authorization
form. You may revoke it at any time unless
we have already acted in reliance upon it.

YOUR RIGHTS REGARDING YOUR
HEALTH INFORMATION

The law gives you many rights regarding
your health information.

... You can ask us to restrict our uses and
disclosures for purposes of treatment
(except emergency treatment), payment or
healthcare operations. We do not have to
agree to do this, but if we agree, we must
honor the restrictions that you want. To
ask for a restriction, send a written request
to Denise Corrales, Contact Person, at the
address at the beginning of this notice.

... You can ask us to communicate with
you in a confidential way, such as by
phoning you at work rather than at home,
or by mailing health information to a
different address. We will accommodate
these requests if they are reasonable, and
if you pay us for any extra cost. If you want
to ask for confidential communications,
send a written request to Denise Corrales,
Contact Person, at the address shown at
the beginning.

... You can ask to see or to get
photocopies of your health information. By
law, there are a few limited situations in
which we can refuse to permit access or
copying. Primarily, however, you will be
able to review or have a copy of your health
information within 30 days of asking us.
You may have to pay for photocopies in
advance. If we deny your request, we will
send you a written explanation, and
instrucitons about how to get an impartial
review of our denial if one is legally
required. By law, we can have one 30-day
extension of the time for us to give you
access or photocopies if we sent you a
written notice of the extension. If you want
to review or get photocopies of your health
information, send a written request to
Denise Corrales, Contact Person, at the
address shown as the beginning.

... You can ask us to amend your health
information if you think that it is incorrect or
incomplete. If we agree, we will amend the
information within 60 days from when you
ask us. We will send the corrected
information to persons who we know got
the wrong information, and others that you
specify. If we do not agree, you can write a
statement of your position, and we will
include it with your health information
along with any rebuttal statement that we
may write. Once your statement of position
and/or rebuttal is included in your health
information, we will send it along
whenever we make a permitted disclosure
of your health information. By law, we can
have one 30-day extension of time to
consider a request for amendment if we
notify you in writing of the extension. If you
want to ask us to amend your health
information, send a written request,
including your reasons for the
amendment, to Denise Corrales, Contact
Person, at the address shown at the
beginning.

... You can get a list of the disclosures that
we have made of your health information
within the past six years (or a shorter
period if you want), except disclosures for
purposes of treatment, payment or health
care operations, disclosures made in
accordance with an authorization signed
by you, and some other limited
disclosures. You are entitled to one such
list per year without charge. If you want
more frequent lists, you will have to pay for
them in advance. We will usually respond
to your request within 60 days of receiving
it, but by law we can have one 30-day
extension of time if we notify you of the
extension in writing. If you want a list, send
a written request to Denise Corrales,
Contact Person at the address shown at
the beginning.

OUR NOTICE OF PRIVACY PRACTICES

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 in
compliance with and 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 here at
our website.

COMPLAINTS

If you think that we have not properly
respected the privacy of your health
information, you are free to complain to us
or to 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 Denise
Corrales, Contact Person at the address
shown at the beginning. If you prefer, you
can discuss your complaint in person or
by phone.

FOR MORE INFORMATION

If you want more information about our
privacy practices, call or visit Denise
Corrales, Contact Person, at the address
or phone number shown at the beginning
of this notice.