NOTICE OF PRIVACY PRACTICES

Northwest Eyecare Professionals
Douglas J. Bosner, O.D.
James C. Bieber, O.D.
Russell S. Fillmore, O.D.
Beth A. Travis, O.D.
2098 Tremont Center
Columbus, OH 43221
614-486-5205
Lynn Crews, HIPAA Compliance Contact

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 respect our legal obligation to keep health information that identifies you private. This Notice
describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

We will use your Protected Health Information (PHI) for treatment. This may include setting up an
appointment for you, examining your eyes, prescribing glasses, contact lenses, or medications. In
addition, we may share your PHI with referring physicians, laboratories, pharmacies, or other
health care personnel providing you treatment.

We will use your PHI to collect payment for treatment you receive in our office. We may do this
with insurance forms filed for you in the mail or sent electronically. We will be sure to only work
with companies with a similar commitment to the security of your health information.

We may disclose your PHI for Health Care Operations. This means our office may use
information in your health record to monitor the performance of the doctors and staff members
providing treatment to you. This information will be used in an effort to continually improve the
quality and effectiveness of the services we provide.

ADDITIONAL USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some situations, the law allows or requires us to use or disclose your health information without
your permission. Some of these situations may never come up in our office. These disclosures
include:

-\tState or Federal law that mandates release of certain health information;

-\tcertain public health purposes, such as contagious disease reporting,
\tinvestigations, and notices to and from the FDA regarding drugs or \t \t\t
\tmedical devices;

-\trelease of information to government authorities about victims of
\tsuspected abuse, neglect, or domestic violence;
\t
-\tuses and disclosures for health oversight activities, such as for the licensing of doctors;
\tfor audits by Medicare or Medicaid; or for investigations of possible violations of health
\tcare laws;

-\tdisclosures for Judicial and administrative proceedings, such as in response to
\tsubpoenas or orders of courts or administrative agencies;

-\tdisclosures to law enforcement agencies to provide information about crimes committed
\tin our office or elsewhere;
\t
-\tdisclosures for health related research;

-\tdisclosures to prevent serious threats to health or safety;

-\tuses or disclosures for specialized government functions, such as protection of high
\tranking government officials, for lawful national intelligence activities, or for military
\tpurposes;

-\tdisclosures of de-identified information;

-\tdisclosures relating to worker's compensation programs;

-\tdisclosures to "business associates" who perform health care operations for us and who
\tcommit to respect the privacy of your health information;

-\tincidental disclosures that are an unavoidable by-product of permitted uses or
\tdisclosures.

Unless you object, we may 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 or write to remind you of scheduled appointments. We may also mail you
appointment reminders on post cards, or leave reminder messages on your answering machine or
with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES OF PHI

This office will obtain your written authorization before using or disclosing PHI about you for the
purposes other than those provided for above (or as otherwise permitted or required by law). You
may revoke this authorization in writing at anytime. Upon receipt of the written revocation, we will
stop using or disclosing PHI about you, except to the extent that we have already taken action in
reliance on the authorization.

YOUR HEALTH INFORMATION RIGHTS

You may obtain a paper copy of this notice upon request at any time. To receive a paper copy,
please contact our office.

You may request a restriction on certain uses and disclosures of PHI. You have the right to
request additional restrictions on our use or disclosure of PHI about you by sending a written
request to our office. We do not have to agree to your request, but if we agree, we must honor
your restrictions.

You have the right to access and copy your PHI . For the most part you will be able to review or
have a copy of your health information within 30 days of asking us. We may charge a small fee
for our time and the photocopying. By law, there are a few limited situations in which we can
refuse to permit access. If you are denied access to your PHI, you may ask that the denial be
reviewed.

If you feel that your PHI is incomplete or incorrect, you may request that we amend it. You may
make this request for as long as we maintain the PHI. To receive an amendment, you must send
a written request to our office. You must include a reason that supports your request. In certain
cases, we may deny your request for amendment. If we deny your request for amendment, you
have the right to file a statement of disagreement and we may give you a rebuttal to your
statement.

You have the right to get a list of the disclosures that we have made of your PHI within the past
six years (or shorter period of time). By law, the list will not include: disclosures for purposes of
treatment, payment, or health care operations, and some other limited disclosures. You are
entitled to one such list per year without charge. If you want more frequent lists, we will collect a
small charge in advance.

You may request additional paper copies of this Notice of Privacy Practice at any time. If you
want additional copies, send a written request to our office contact person .

We are required by law to maintain the privacy of your health information and to provide you with
this Notice of our Privacy Practices. We are required to practice the policies and procedures
described in this notice but we reserve the right to change the terms of our Notice. If we change
our privacy practices, we will be sure all our patients receive the revised Notice.

Your have the right to express complaints to us or to the U.S. Department of Health and Human
Services, Office of Civil Rights, if you believe your privacy rights have been compromised. If you
want to complain to us, send a written complaint to the office contact person listed at the top of
this notice. If you prefer, you can discuss your complaint in person or by phone.