madeira optical privacy policy

NOTICE OF PRIVACY PRACTICES

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.

THIS NOTICE IS EFFECTIVE April 14th, 2003 UNTIL FURTHER NOTICE.

Legal Requirements
Madeira Optical is required by law to maintain the privacy of your protected health information. We
are required to abide by the terms of this notice as it is currently stated, and reserve the right to
change this notice and make the new policies effective for all protected health information that we
maintain. The policies in any new notice will not be in effect until they are posted to this site and are
available in our office. We will make any new notice available to you upon request.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Routine Uses and Disclosures of Protected Health Information for Treatment, Payment or Health
Care Operations

As a patient, you have certain rights relating to the uses and disclosures of your protected health
information. Under the Health Insurance Portability and Accountability Act (HIPAA), Madeira Optical
can use and disclose your protected health information without your specific permission for treatment,
payment and health care operations. Set out below are examples of the uses and disclosures of your
protected health information Madeira Optical is permitted to make for these routine purposes. While
this list is not exhaustive, it should give you an idea of the everyday uses and disclosures "behind" the
scenes that are essential to the care you receive.

a) Treatment - We may use or disclose your health information for purposes of providing treatment to
you. For example, your protected health information will be used to diagnose and counsel you
regarding your health condition and appropriate treatment options. We may also use and disclose
your protected health information to provide you with information regarding possible alternative
treatment options and other health-related benefits and services that we believe might interest you.
For example, we may use or disclose your health information to provide you with appointment
reminders via phone, e-mail or letter.

b) Payment - We may use and disclose your health information to obtain payment for services we
provide you. For example, we may communicate your protected health information to you insurance
company so that it can process payment for your office visit.

c) Health care operations - We may use and disclose your health information in connection with our
healthcare operations. Healthcare operations include quality assessment and improvement activities,
reviewing the competency or qualifications of healthcare professionals, evaluating provider
performance, conducting training programs, accreditation, certification, licensing or credentialing
activities.

Other Uses and Disclosures of Protected Health Information Madeira Optical is Permitted or Required
to Make Without Your Authorization

Most uses and disclosures that do not fall under treatment, payment, or health care operations will
require your written authorization. However, there are exceptions to this general rule pursuant to
which we are permitted or required to make certain uses and disclosures or your protected health
information. These situations include:
Required by the Secretary of Health and Human Services

We may be required to disclose your protected health information to the Secretary of Health and
Human Services to investigate or determine our compliance with the federal privacy law.

Required by Law
We may also use or disclose your health information when we are required to do so by state or
federal law.

Public Health
We may disclose your protected health information for public health activities, such as disclosures to
a public health authority or other government agency that is permitted by law to
collect or receive the information (e.g., the Food and Drug Administration).

Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably believe that you
are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes.

Health Oversight
We may disclose protected health information to a health oversight agency for activities authorized
by law, such as: civil or criminal investigations; inspections; licensure or disciplinary actions; or other
activities necessary for appropriate oversight, governmental health benefit programs, or compliance
with laws.

Judicial and Administrative Proceedings
We may disclose protected health information in response to a court or agency order, and, in some
cases, in response to a subpoena or other lawful process not accompanied by a court order.

Law Enforcement
We may disclose protected health information for law enforcement purposes, such as providing
information to the police about the victim of a crime.
Coroners, Medical Examiners, and Funeral Directors
We may disclose protected health information to a coroner, medical examiner, or funeral director if it
is needed to carry out their duties. We also may disclose protected health information to facilitate
organ donation or transplantation.

Research

We may disclose your protected health information to researchers when the research is being
conducted under established protocols to ensure the privacy of your information.

Serious Threat to Health or Safety

Your protected health information may be disclosed if we believe it is necessary to prevent a serious
and imminent threat to the public health or safety and it is to someone we reasonably believe is able
to prevent or lessen the threat.

Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a
family member, or another person responsible for your care, using our professional judgment. We
will only disclose health information that is directly relevant to the person's involvement in your
healthcare.

National Security
We may disclose the health information of Armed Forces personnel to military authorities under
certain circumstances. We may disclose health information to authorized federal officials required for
lawful intelligence, counterintelligence and other national security activities.

Inmates
We may disclose health information of inmates to the appropriate authorities under certain
circumstances.

Workers' Compensation
Your protected health information may be disclosed to comply with workers' compensation laws and
other similar programs.

Disclosures to Other Parties for Conducting Permitted Activities
Madeira Optical may conduct the above-described activities ourselves, or we may use other entities
to perform those operations. In those instances where we disclose your protected health information
to a third party acting on our behalf, we will protect your protected health information through an
appropriate privacy agreement.

Other Uses and Disclosures of Protected Health Information Based Upon Your Written
Authorization

Marketing
We will not use your health information for marketing communications without your written
authorization.

Other uses and disclosures of your protected health information not described above will be made
only with your written authorization. You may revoke your authorization (in writing) through our
practice at any time, except to the extent that we have taken action in reliance on the authorization.

YOUR RIGHTS
You have the right to request a restriction on certain uses and disclosures of your protected health
information. This means that you may ask us not to use or disclose any part of your protected health
information for purposes of treatment, payment, or health care operations. You may also request that
any part of your protected health information not be disclosed to family members or friends who may
be involved in your care. Your request must be in writing and must state the specific restriction
requested and to whom you want the restriction to apply.

Madeira Optical is not required to agree to such a restriction. If we do agree, we will abide by your
restriction unless we need to use your protected health information to provide emergency treatment.
In addition, we may elect to terminate the restriction at any time. You have the right to request to
receive information from us by an alternative means or at an alternative location if you believe it
would enhance your privacy. For example, you may request that we send written communications to
an alternative address. We will attempt to accommodate all reasonable requests, and will not request
an explanation from you as to the basis for your request.

You have the right to inspect and copy your protected health information. If you would like to see or
copy your protected health information, we are required to provide you access to your protected
health information for inspection and copying within 30 days after receipt of your request (60 days if
the information is stored off-site). We may charge you a reasonable fee to cover duplicating costs. In
addition, there may be situations where we may decide to deny your request for access. For
example, we may deny your request if we believe the disclosure will endanger your life or health, or
that of another person. Depending on the circumstances of the denial, you may have a right to have
this decision reviewed.
You have the right to amend your protected health information. This means you may request an
amendment of your protected health information in our records for as long as we maintain this
information. We will respond to your request within 60 days (with up to a 30-day extension, if needed).
We may deny your request if, for example, we determine that your protected health information is
accurate and complete. If we deny your request, we will send you a written explanation and allow you
to submit a written statement of disagreement.
You have the right to receive an accounting of certain disclosures we have made of your protected
health information. An accounting is a record of the disclosures that have been made of protected
health information. This right generally applies to non-routine disclosures, i.e., for purposes other than
treatment, payment, or health care operations as described in this Notice, made in the six-year period
prior to your request (although you are free to request an accounting for a shorter period). We are
required to provide the accounting within 60 days (with one 30-day extension, if needed) and to
provide one accounting free of charge in any 12-month period (for more frequent requests, a
reasonable fee may be charged).

You have the right to obtain a paper copy of this notice from Madeira Optical.

COMPLAINTS
If you believe your privacy rights have been violated, you have the right to report such alleged
violations to Madeira Optical, and we will promptly investigate the matter. You may file a complaint
with Madeira Optical by contacting our office. Rest assured we will not retaliate against you in any way
for filing a complaint about our privacy practices. You may also contact the Secretary of Health and
Human Services.

For further information about Madeira Optical's privacy policies, please contact our Privacy Officer at
the following address or phone number:

Madeira Optical
7111 Miami Ave.
Cincinnati, OH, 45243
(513) 561-7076

THANK YOU