Privacy Policy

Vision Wellness

10750 W. McDowell Rd Bldg. A100, Avondale, AZ 85392

Phn: 623.877.3007 -- Fax: 623.877.4488

4236 N Verrado Way Ste. 103, Buckeye, AZ 85396

Phn: 623.792.1955 -- Fax: 623.234.3810

Contact person: Adam Lee info@myvisionwellness.com

THIS NOTICE DECRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to

give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you

have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATION

The most common reason why we use or disclose your health information is for treatment, payment or heath care

operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for

you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled,

referring you to another doctor or clinic for eye care services, or getting copies of your health information from another

professional that you may have seen before us. Examples of how we use or disclose your health information for payment

purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills

or claims; and collection unpaid amounts (either ourselves or through a collection agency or attorney). “Health Care

Operation” mean those administrative and managerial functions that we have to do in order to run our office. Examples of

how we use or disclose your health information for health care operations are: financial or billing audits; internal quality

assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning;

decisions; and outside storage of your records. Your health information is not shared with third-parties for marketing

purposes.

We routinely use your health information inside our offices for these purposes without any special permission. If

we need to disclose your health information outside of your office for these reasons, we will ask for special written

permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limits situation, 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 come up at our office at all. Such uses or

disclosures are:

 When a state or federal law mandates that certain health information be reported for a specific purpose;

 For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to

and from the federal 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 oversite activities, such as for the licensing of doctors; for audits by Medicare or

Medicaid; or for investigation of possible violations of health care laws;

 Disclosures for judicial and administrative proceedings, such as in response to subpoenas or order of courts or

administrative agencies;

 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;

 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 donation;

 Use or disclosures for health related research;

 Use and disclosures to prevent a serious threat to heal to safety;

 Uses or disclosures for specialized government functions, such as for the protection of the president or high

ranking officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of

members of the foreign service;

 Disclosures of de-identified information;

 Disclosures relating to worker’s compensation programs;

 Disclosure of a “limited data set” for research, public health, or health care operations;

 Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;

 Disclosures to “business associates” who preform health care operation for us and who commit to respect the

privacy of your health information.

Unless you object we will also share relevant information about your care with your family or friends who are helping

you with your eye care.

APPOINTMENT REMINDERS

We may call, text, E-mail or write to remind you of scheduled appointment, or that it is time to make a routine

appointment. We may also call, text, E-mail or write to notify you of other treatments or services available at our office that

might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a

reminder message on your home answering machine, send a text message or with someone who answers your phone if

you are not home.

OTHER USES AND DISCLUSRES

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 by federal law. Sometimes, we may initiate the authorization

process if the use or disclosure is our idea. Sometimes you may initiate the process if it’s your idea for us to send your

information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you

can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. 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 office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMAION

The law gives you many rights regarding your health information. You can:

 ask us to restrict our uses and disclosure for purposes of treatment (except emergency treatment), payment or

health care 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 the office contact person at the address, or fax shown

at the beginning of this Notice.

 ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by

mailing health information to a different address, or by using E-mail to your personal E-mail address. We will

accommodate these requests if they are reasonable, and if you pay for us for any extra cost. If you want to ask for

confidential communications, send a written request to the office contact person at the address, fax or E-mail

shown at the beginning of this Notice.

 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. For the most part, however, you will be able to review or have a copy of

your health information within 30 days of asking us (or 60 days if the information is stored off-sight). You may

have to pay for photocopies in advance. If you deny your request, we will send you a written explanation, and

instructions about how to get impartial review of your denial if one is legally available. By law, we can have one 30

day extension of the time for us to give you access or photocopies if we send you a written notice of the

extension. If you want to review or get photocopies of your health information, send a written request to the office

contact person at the address or fax shown at the beginning of this Notice.

 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 asked 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 our rebuttals 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 you health information, send a written request, including your reasons for the amendment, to the

office contact person at the address, email, or fax shown at the beginning of the Notice.

 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). By law, the list will not include: disclosures of purposes of treatment, payment or heath care

operation; disclosures with your authorization; incidental disclosures; disclosures required by law; 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 the office contact person at the address or fax shown at the beginning of this Notice.

 get additional paper copies of this notice of privacy practices upon request. It does not matter whether you got

one electronically or in paper for already. If you want additional paper copies, send a written request to the office

contact person at the address or fax shown at the beginning of this Notice

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 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, we have copies available in our office,

and post it on our Web site.

COMPLAINTS

If you think that we do not have properly respected the privacy of your health information, you are free to complain

to us or 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, sent a written complaint to the office contact person at the address, fax

or E-mail shown at the beginning of the Notice. 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 the office contact person at the address or

phone number shown at the beginning of this Notice.