NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW EYEBOX MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU
CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY

EyeBox is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, whether created by EyeBox or received by EyeBox from other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. EyeBox will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.

EyeBox reserves the right to change the terms of this Notice and make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information not Requiring Your Consent

EyeBox may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment, healthcare operations, and when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare providers treating you. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.

Treatment may include:

  • Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;
  • Consultations between healthcare providers concerning a patient;
  • Referrals to other providers concerning a new patient;
  • Referrals to nursing homes, foster care homes, or home health agencies.

For example, EyeBox may determine that you require the services of a specialist. In referring you to another doctor, EyeBox may share or transfer your healthcare information to that doctor.

Payment activities may include:

  • Activities undertaken by EyeBox to obtain reimbursement for services provided to you;
  • Determining your eligibility for benefits or health insurance coverage;
  • Managing claims and contacting your insurance company regarding payment;
  • Collection activities to obtain payment for services provided to you;
  • Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
  • Obtaining pre-certification and pre-authorization of services to be provided by you.

For example, EyeBox will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided by you.

Healthcare operations may include:

  • Contacting healthcare providers and patients with information about treatment alternatives;
  • Conducting quality assessment and improvement activities;
  • Conducting outcome evaluation and development of clinical guidelines;
  • Protocol development, case management, or care coordination;
  • Conducting and arranging for medical review, legal services, and auditing functions;
  • Disclosures to business associates and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA.

For example, EyeBox may use your diagnosis, treatment and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

EyeBox may contact you, by telephone, e-mail, or text to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.

We may disclose your protected health information to family members or friends who may be involved with your treatment or eye care without your permission. Health information may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designated in an incapacitated patient's healthcare power of attorney; or the personal representative or spouse of a deceased patient. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for healthcare prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to use prior to your death.

There are additional situations when EyeBox is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:

  • As permitted or required by law.

    In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe the wound occurred as a result of a crime. Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.
  • For health oversight activities.

    We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification.
  • Judicial and Administrative Proceedings.
  • Patient healthcare records, including treatment records may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.
  • For workers' compensation.

    We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.

Uses and Disclosures of Your Protected Health information Requiring Your Consent

EyeBox will not make available without your authorization for the following specific uses:

  • Marketing Activities - We must obtain your authorization prior to disclosing any of your health information for marketing purposes.
  • Sale of health information - We do not currently sell or plan to sell your health information.
  • Psychotherapy notes - Although we do not create or maintain psychotherapy notes on our patients we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

EyeBox will not make any other use or disclosure of your protected health information without your authorization. You may revoke such authorization at any time, except to the extent that EyeBox has taken action in reliance thereon. Any revocation must be in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by EyeBox to carry out treatment, payment, or health care operations and is not otherwise required by law and such information pertains solely to a healthcare item or service for which you have paid in full (or for which another person than the health plan have paid in full on your behalf). You must request such a restriction in writing. Also, a restriction would not apply when we are required by law to disclose certain healthcare information.

You have the right to review and or obtain a copy of your health care records, with the exception of psychotherapy notes or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. EyeBox may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.

You may request that EyeBox send protected health information, including billing information, to you by alternative means, or by alternative locations. You may also request that EyeBox not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that EyeBox amend portions of your health care records, as long as such information is maintained by us. You must submit this request in writing and under certain circumstances the request may be denied.

You may request and receive a paper copy of this notice, if you had previously received or agreed to receive the notice electronically.

Any person may file a complaint with EyeBox and/or the secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with EyeBox, please contact the Security Privacy Officers at the following:

  • Security Privacy Officers - EyeBox
  • P.O. Box 26602
  • Brooklyn, NY 11202
  • 332-233-5950

It is the policy of EyeBox that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non compliance or violation of the privacy standards.

(EyeBox Optometry PLLC) NOTICE OF PRIVACY PRACTICES NOTICE REVISED AND EFFECTIVE DECEMBER 19, 2023)

NOTICE OF PRIVACY
PRACTICES

THIS NOTICE DESCRIBES HOW EYEBOX MAY USE AND DISCLOSE YOUR
HEALTHCARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW CAREFULLY

EyeBox is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, whether created by EyeBox or received by EyeBox from other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. EyeBox will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.

EyeBox reserves the right to change the terms of this Notice and make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information not Requiring Your Consent

EyeBox may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment, healthcare operations, and when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare providers treating you. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.

Treatment may include:

  • Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;
  • Consultations between healthcare providers concerning a patient;
  • Referrals to other providers concerning a new patient;
  • Referrals to nursing homes, foster care homes, or home health agencies.

For example, EyeBox may determine that you require the services of a specialist. In referring you to another doctor, EyeBox may share or transfer your healthcare information to that doctor.

Payment activities may include:

  • Activities undertaken by EyeBox to obtain reimbursement for services provided to you;
  • Determining your eligibility for benefits or health insurance coverage;
  • Managing claims and contacting your insurance company regarding payment;
  • Collection activities to obtain payment for services provided to you;
  • Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
  • Obtaining pre-certification and pre-authorization of services to be provided by you.

For example, EyeBox will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided by you.

Healthcare operations may include:

  • Contacting healthcare providers and patients with information about treatment alternatives;
  • Conducting quality assessment and improvement activities;
  • Conducting outcome evaluation and development of clinical guidelines;
  • Protocol development, case management, or care coordination;
  • Conducting and arranging for medical review, legal services, and auditing functions;
  • Disclosures to business associates and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA.

For example, EyeBox may use your diagnosis, treatment and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

EyeBox may contact you, by telephone, e-mail, or text to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.

We may disclose your protected health information to family members or friends who may be involved with your treatment or eye care without your permission. Health information may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designated in an incapacitated patient's healthcare power of attorney; or the personal representative or spouse of a deceased patient. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for healthcare prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to use prior to your death.

There are additional situations when EyeBox is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:

  • As permitted or required by law.

    In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe the wound occurred as a result of a crime. Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.
  • For health oversight activities.

    We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification.
  • Judicial and Administrative Proceedings.
  • Patient healthcare records, including treatment records may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.
  • For workers' compensation.

    We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.

Uses and Disclosures of Your Protected Health information Requiring Your Consent

EyeBox will not make available without your authorization for the following specific uses:

  • Marketing Activities - We must obtain your authorization prior to disclosing any of your health information for marketing purposes.
  • Sale of health information - We do not currently sell or plan to sell your health information.
  • Psychotherapy notes - Although we do not create or maintain psychotherapy notes on our patients we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

EyeBox will not make any other use or disclosure of your protected health information without your authorization. You may revoke such authorization at any time, except to the extent that EyeBox has taken action in reliance thereon. Any revocation must be in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by EyeBox to carry out treatment, payment, or health care operations and is not otherwise required by law and such information pertains solely to a healthcare item or service for which you have paid in full (or for which another person than the health plan have paid in full on your behalf). You must request such a restriction in writing. Also, a restriction would not apply when we are required by law to disclose certain healthcare information.

You have the right to review and or obtain a copy of your health care records, with the exception of psychotherapy notes or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. EyeBox may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.

You may request that EyeBox send protected health information, including billing information, to you by alternative means, or by alternative locations. You may also request that EyeBox not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that EyeBox amend portions of your health care records, as long as such information is maintained by us. You must submit this request in writing and under certain circumstances the request may be denied.

You may request and receive a paper copy of this notice, if you had previously received or agreed to receive the notice electronically.

Any person may file a complaint with EyeBox and/or the secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with EyeBox, please contact the Security Privacy Officers at the following:

  • Security Privacy Officers - EyeBox
  • P.O. Box 26602
  • Brooklyn, NY 11202
  • 332-233-5950

It is the policy of EyeBox that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non compliance or violation of the privacy standards.

(EyeBox Optometry PLLC) NOTICE OF PRIVACY PRACTICES NOTICE REVISED AND EFFECTIVE DECEMBER 19, 2023)

NOTICE OF
PRIVACY
PRACTICES

THIS NOTICE DESCRIBES HOW EYEBOX
MAY USE AND DISCLOSE YOUR
HEALTHCARE INFORMATION AND HOW
YOU CAN OBTAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW
CAREFULLY

EyeBox is required by law to maintain the privacy of your protected health information. This information consists of all records related to your health, including demographic information, whether created by EyeBox or received by EyeBox from other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. EyeBox will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information.

EyeBox reserves the right to change the terms of this Notice and make any new provisions effective for all protected health information that we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information not Requiring Your Consent

EyeBox may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment, healthcare operations, and when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare providers treating you. There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results.

Treatment may include:

  • Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;
  • Consultations between healthcare providers concerning a patient;
  • Referrals to other providers concerning a new patient;
  • Referrals to nursing homes, foster care homes, or home health agencies.

For example, EyeBox may determine that you require the services of a specialist. In referring you to another doctor, EyeBox may share or transfer your healthcare information to that doctor.

Payment activities may include:

  • Activities undertaken by EyeBox to obtain reimbursement for services provided to you;
  • Determining your eligibility for benefits or health insurance coverage;
  • Managing claims and contacting your insurance company regarding payment;
  • Collection activities to obtain payment for services provided to you;
  • Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;
  • Obtaining pre-certification and pre-authorization of services to be provided by you.

For example, EyeBox will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided by you.

Healthcare operations may include:

  • Contacting healthcare providers and patients with information about treatment alternatives;
  • Conducting quality assessment and improvement activities;
  • Conducting outcome evaluation and development of clinical guidelines;
  • Protocol development, case management, or care coordination;
  • Conducting and arranging for medical review, legal services, and auditing functions;
  • Disclosures to business associates and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA.

For example, EyeBox may use your diagnosis, treatment and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

EyeBox may contact you, by telephone, e-mail, or text to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders.

We may disclose your protected health information to family members or friends who may be involved with your treatment or eye care without your permission. Health information may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designated in an incapacitated patient's healthcare power of attorney; or the personal representative or spouse of a deceased patient. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for healthcare prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to use prior to your death.

There are additional situations when EyeBox is permitted or required to use or disclose your protected health information without your consent or authorization. Examples include the following:

  • As permitted or required by law.

    In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe the wound occurred as a result of a crime. Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.
  • For health oversight activities.

    We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification.
  • Judicial and Administrative Proceedings.
  • Patient healthcare records, including treatment records may be disclosed pursuant to a lawful court order. A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.
  • For workers' compensation.

    We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.

Uses and Disclosures of Your Protected Health information Requiring Your Consent

EyeBox will not make available without your authorization for the following specific uses:

  • Marketing Activities - We must obtain your authorization prior to disclosing any of your health information for marketing purposes.
  • Sale of health information - We do not currently sell or plan to sell your health information.
  • Psychotherapy notes - Although we do not create or maintain psychotherapy notes on our patients we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

EyeBox will not make any other use or disclosure of your protected health information without your authorization. You may revoke such authorization at any time, except to the extent that EyeBox has taken action in reliance thereon. Any revocation must be in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by EyeBox to carry out treatment, payment, or health care operations and is not otherwise required by law and such information pertains solely to a healthcare item or service for which you have paid in full (or for which another person than the health plan have paid in full on your behalf). You must request such a restriction in writing. Also, a restriction would not apply when we are required by law to disclose certain healthcare information.

You have the right to review and or obtain a copy of your health care records, with the exception of psychotherapy notes or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding. EyeBox may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.

You may request that EyeBox send protected health information, including billing information, to you by alternative means, or by alternative locations. You may also request that EyeBox not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that EyeBox amend portions of your health care records, as long as such information is maintained by us. You must submit this request in writing and under certain circumstances the request may be denied.

You may request and receive a paper copy of this notice, if you had previously received or agreed to receive the notice electronically.

Any person may file a complaint with EyeBox and/or the secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with EyeBox, please contact the Security Privacy Officers at the following:

  • Security Privacy Officers - EyeBox
  • P.O. Box 26602
  • Brooklyn, NY 11202
  • 332-233-5950

It is the policy of EyeBox that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non compliance or violation of the privacy standards.

(EyeBox Optometry PLLC) NOTICE OF PRIVACY PRACTICES NOTICE REVISED AND EFFECTIVE DECEMBER 19, 2023)