Privacy Notice

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 takes effect on/or before April 14, 2003 and remains in effect until we replace it.

OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your protected health information (PHI) is important to us. We understand that your PHI is personal and we are committed to protecting it. We create a record of the care and services you receive at our office. We need this record to provide you with quality care and to comply with certain legal requirements. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION Your health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for purpose of providing health care services to you, to obtain payment for services, to support the operation of the physician's practice and any other use required by law. FOR TREATMENT: We will use or disclose information for treatment purposes in the following ways: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and sending the information by mail, phone, fax or electronically to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care, low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. FOR PAYMENT: Your health information will be used, as needed, to obtain payment for your health care services. For example we will ask you about your vision care plan, or other sources for payment; preparing and sending bills or claims; collecting unpaid amounts (either ourselves or through a collection agency or attorney). We will keep your member identification number or social security number on file in writing or in the computer for use in obtaining insurance authorization and filing claims. FOR HEALTH CARE OPERATIONS: Your health information will be used for those administrative and managerial functions that we have to do in order to run our office. For example your health information will be used for financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We may also call, write, or otherwise notify you of scheduled appointments, or that it is time to make a routine appointment. We may also call, write, or otherwise notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we may mail you an appointment reminder on a postcard, leave a reminder message on your answering service or with someone who answers the phone if you are not there, or we may notify you electronically by e-mail or facsimile concerning appointments. We may use a sign in sheet at the reception desk where you will be asked to sign your name and purpose for your visit. We may also call you by name in the waiting room when we are ready to see you. ADDITIONAL USES AND DISCLOSURES: We may use or disclose your health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases; Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker's Compensation: Inmates: Required Uses and Disclosures: disclosures of de-identified information: incidental disclosures that are an unavoidable by-product for permitted uses or disclosures: disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information. OTHER USES AND DISCLOSURES: We will not make any other uses or disclosures of your health information unless you sign a written "authorization form". The content of an "authorization form" is determined be federal law. Sometimes, we may initiate the authorization process. If you are asked to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the Privacy Officer at this practice. Sometimes, you may initiate the process to send your information to someone else. In this situation you must submit a properly completed authorization form, or you can use one of ours.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You may also request that any part of your health information not be disclosed to family members or friends who may be involved in your care or for notification purposes described in this policy. We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must send your request in writing to the Privacy Officer at this practice. In your request, you must tell what information you want to limit and to whom it will apply. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request how we should send communications to you about medical matters, and where you would like those communications sent. To request confidential communications, you must make your request in writing to the Privacy Officer at this practice. We will accommodate all reasonable requests; however we reserve the right to charge you a cost-based fee for any non-customary expenses involved. Your request must specify how or where you wish to be contacted. RIGHT TO INSPECT AND COPY: You have the right to inspect or get a copy of your health information. Usually this includes medical and billing records, but does not include information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. Your request must be submitted in writing to the Privacy Officer at this practice. Your request will be answered within 30 days (or 60 days if the information is stored off-site). We reserve the right to charge a fee for the costs of copying, mailing and other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial. RIGHT TO AMEND: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if the information was not created by us, is not part of the health information kept at this practice, is not part of the information which you would be permitted to inspect and copy, or which we deem to be accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized request for information pertaining to the appropriate portion of your record. RIGHT TO AN ACCOUNTING OF NON-STANDARD DISCLOSURES: You have the right to request a list of the disclosures we made of health information about you. By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. To request this list, you must submit your request in writing to the Privacy Officer at this practice. Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years, and may not include dates before April 14, 2003. The first list you request in a 12-month period is free. For additional lists, we reserve the right to charge you for the cost of providing the list. RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right to a paper copy of our current Notice of Privacy Practices at any time. To obtain a paper copy of the current Notice, please send a request in writing to the Privacy Officer at this practice. COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint. OUR NOTICE OF PRIVACY PRACTICES: We are required by law to abide by the terms of this Notice of Privacy Practices. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post the current Notice, with the effective date in our office, have copies available in our office, and post it on our Web site. FOR MORE INFORMATION: If you want more information about our privacy practices, you may contact the Privacy Officer at this practice.

CONTACT INFORMATION For further information about Ousley Vision Center's privacy policies, please contact Privacy Officer: Office Manager at the following address or phone number:

2430 FM 407, Suite A Highland Village, Texas 75077 (972)-317-3937