Your Information. Your Rights. Our Responsibilities.

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.

We understand that your medical information is personal, and we are committed to protecting your medical information. While you are a patient at this Center (“Center”), we create records of the care provided to you. We need these records to provide you with quality health care and to comply with certain legal requirements.

This Notice of Privacy Practices (the “Privacy Practices” or “Notice”) describes how we may use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your medical information under law.

Privacy Practices describe the privacy practices of this Organization as well as our affiliated surgeons (referred to as “we” throughout this Notice). We will share information with each other as necessary to carry out our respective treatment obligations, payment activities and health care operations.

The Center has several functions to perform, including the immediate and ongoing care of patients, the continuing education of health care professionals, patients, and the community, and basic clinical research. All of these activities must be conducted with an overriding concern for the values and dignities of our patients.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to inspect and obtain an electronic or paper copy of your medical record and other health information we have about you. Under certain circumstances, we may deny your request.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Reasons a request may be denied include, but are not limited to:
    • Information was not created by the practice;
    • Information is not part of the medical information maintained by or for the practice;
    • Information is not medical information you are permitted to inspect;
    • Information is accurate and complete in the medical record.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • You may revoke any authorization you have provided to use or disclose your medical information except to the extent that action has already been taken in reliance on such authorization.

Get a copy of this privacy notice

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • Your Personal Representative may exercise your rights on your behalf. A Personal Representative may include your guardian if you are a minor, lack decision-making capacity or are legally incompetent, or a person you have authorized to act on your behalf as specified in a written document (such as a power of attorney). We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the following information:

Privacy Officer



  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.


Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We may use and disclose your medical information to provide, coordinate, or manage your health care and related services. For example, we may disclose your medical information to the doctors and technicians that care for you while you are undergoing surgery or an optometrist that cares for you after surgery to ensure that they have the necessary information to treat you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.


Run our organization

We may use or disclose your medical information for our internal operations, which include activities necessary to operate this Center and provide our patients with high quality patient care. For example, we may use your medical information for quality improvement purposes to evaluate the care provided to you. We may also use a sign-in sheet at the reception desk asking for your name or call you by name in the waiting area. We may use your medical information to contact you to remind you of appointments, tell you about or recommend possible treatment options or alternatives that may be of interest to you, or inform you about other health related benefits and services that may be of interest to you.

Example: We use health information about you to manage your treatment and services.

Billing and Payment for your services

Your medical information may be disclosed, as needed, to obtain payment from your insurance company or other person responsible for payment for your health care services. For example, we may disclose your medical information to an insurance company so that it can determine your eligibility or coverage for insurance benefits.

Example: We give information about you to your health insurance plan so it will pay for your services.

De-Identified Information

We may use your PHI to create “de-identified” information, which means that information that can be used to identify you will be removed. There are specific rules under the law about what type of information needs to be removed before information is considered de-identified. Once information has been de-identified as required by law, it is no longer subject to this Notice, and we may use it for any purpose without any further notice or compensation to you.


How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Other Permitted Uses and Disclosures  

  1. Unless you object, our staff and the optometrist and surgeons caring for you may disclose your medical information to a family member, relative, close friend, or other person that you identify.
  2. Unless you object, our staff or the optometrist and surgeons caring for you may disclose your name, treatment date, and contact information to a local, partnering optometrist who may prompt you with an annual appointment reminder to facilitate follow up care.
  3. We may be required by law to disclose your medical information.
  4. We will make your medical information available to you, the Secretary of the Department of Health and Human Services, and as otherwise required by Federal and State law.
  5. We may disclose your medical information to a public health agency to help prevent or control disease, injury or disability. This may include disclosing your medical information to report certain diseases, death, abuse, neglect or domestic violence or reporting information to the Food and Drug Administration, if you experience an adverse reaction from any of the drugs, supplies or equipment that we use.
  6. We may disclose your medical information to government agencies so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs.
  7. We may disclose your medical information as authorized by law to comply with workers’ compensation laws.
  8. We may disclose your medical information in the course of a judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in response to a subpoena, discovery request, or other lawful process.
  9. We may disclose your medical information to law enforcement officials to report or prevent a crime, locate or identify a suspect, fugitive or material witness or assist a victim of a crime.
  10. We may use or disclose your medical information for research purposes when the research received approval of an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your medical information.
  11. If you are a member of the armed forces, we may disclose your medical information as required by military command authorities or to evaluate your eligibility for veteran’s benefits, for conducting national security and intelligence activities, including providing protective services to the President or other persons provided protective services under Federal law.
  12. We may disclose your medical information to coroners, medical examiners and funeral directors so that they can carry out their duties or for purposes of identification or determining cause of death.
  13. We may disclose your medical information to people involved with obtaining, storing or transporting organs, eyes, or tissue of cadavers for donation purposes.
  14. We may share your medical information with third party “business associates” that perform various services for us. For example, we may disclose your medical information to third parties to provide billing or copying services. To protect your medical information, however, we require our business associates to safeguard your medical information.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

  • This Notice of Privacy Practices is effective May 1, 2024
  • Privacy Officer:
    • Corrinne Ehlert

Phone: 615-819-6090