Privacy Notice
NOTICE OF PRIVACY PRACTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW ITCAREFULLY.
THIS NOTICE IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.
Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected
health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), [Practice
Name here] can use your protected health information for treatment, payment and health care
operations.
a) Treatment - We may use or disclose your health information to a physician or other
healthcare provider providing treatment to you.
b) Payment - We may use and disclose your health information to obtain payment for services
we provide you.
c) Health care operations - We may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include quality assessment and improvement
activities, reviewing the competency or qualifications of healthcare professionals, evaluating
provider performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization
Most uses and disclosures that do not fall under treatment, payment, health care operations will
require your written authorization. Upon signing, you may revoke your authorization (in writing)
through our practice at any time.
Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a
family member, or another person responsible for your care, using our professional judgment.
We will only disclose health information that is directly relevant to the person's involvement in
your healthcare.
Marketing
We will not use your health information for marketing communications without your written
authorization.
Required by Law
We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes.
We may disclose your health information to the extent necessary to avert a serious threat to
your or other people's health or safety.
National Security
We may disclose the health information of Armed Forces personnel to military authorities under
certain circumstances. We may disclose health information to authorized federal officials
required for lawful intelligence, counterintelligence and other national security activities. We may
disclose health information of inmates or patients to the appropriate authorities under certain
circumstances.
Appointment Reminders
We may use or disclose your health information to provide you with appointment reminders via
phone, e-mail or letter.
Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in writing). The
request for restriction may be denied if the information is required for treatment, payment or
health care operations.
-You have the right to receive confidential communications regarding your protected health
information.
-You have the right to inspect and copy your protected health information.
-You have the right to amend your protected health information.
-You have the right to receive an account of disclosures of your protected health information.
-You have the right to a paper copy of this notice of privacy practices.
Legal Requirements
[Practice Name here] is required by law to maintain the privacy of your protected health
information. We are required to abide by the terms of this notice as it is currently stated, and
reserve the right to change this notice. The policies in any new notice will not be in effect until
they are posted to this site, or are available within our office.
Complaints
If you have complaints regarding the way your protected health information was handled, you
may submit a complaint in writing to our office. You will not be retaliated against in any manner
for a complaint.
Contact Information
For further information about Santa Clarita Vision Center 's privacy policies, please contact us at ...
Santa Clarita Vision Center
26506 Bouquet canyon Road
Saugus, CA 91350
661 297-2020
Dr. Leonard Forbes
Optometrist
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW ITCAREFULLY.
THIS NOTICE IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.
Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected
health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), [Practice
Name here] can use your protected health information for treatment, payment and health care
operations.
a) Treatment - We may use or disclose your health information to a physician or other
healthcare provider providing treatment to you.
b) Payment - We may use and disclose your health information to obtain payment for services
we provide you.
c) Health care operations - We may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include quality assessment and improvement
activities, reviewing the competency or qualifications of healthcare professionals, evaluating
provider performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization
Most uses and disclosures that do not fall under treatment, payment, health care operations will
require your written authorization. Upon signing, you may revoke your authorization (in writing)
through our practice at any time.
Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a
family member, or another person responsible for your care, using our professional judgment.
We will only disclose health information that is directly relevant to the person's involvement in
your healthcare.
Marketing
We will not use your health information for marketing communications without your written
authorization.
Required by Law
We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes.
We may disclose your health information to the extent necessary to avert a serious threat to
your or other people's health or safety.
National Security
We may disclose the health information of Armed Forces personnel to military authorities under
certain circumstances. We may disclose health information to authorized federal officials
required for lawful intelligence, counterintelligence and other national security activities. We may
disclose health information of inmates or patients to the appropriate authorities under certain
circumstances.
Appointment Reminders
We may use or disclose your health information to provide you with appointment reminders via
phone, e-mail or letter.
Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in writing). The
request for restriction may be denied if the information is required for treatment, payment or
health care operations.
-You have the right to receive confidential communications regarding your protected health
information.
-You have the right to inspect and copy your protected health information.
-You have the right to amend your protected health information.
-You have the right to receive an account of disclosures of your protected health information.
-You have the right to a paper copy of this notice of privacy practices.
Legal Requirements
[Practice Name here] is required by law to maintain the privacy of your protected health
information. We are required to abide by the terms of this notice as it is currently stated, and
reserve the right to change this notice. The policies in any new notice will not be in effect until
they are posted to this site, or are available within our office.
Complaints
If you have complaints regarding the way your protected health information was handled, you
may submit a complaint in writing to our office. You will not be retaliated against in any manner
for a complaint.
Contact Information
For further information about Santa Clarita Vision Center 's privacy policies, please contact us at ...
Santa Clarita Vision Center
26506 Bouquet canyon Road
Saugus, CA 91350
661 297-2020
Dr. Leonard Forbes
Optometrist