Ocular Symptoms* To help our doctor provide the best care for you, please let us know if you are you currently experiencing or have experienced any of the following? Please select ALL that apply below or select NONE from list. After making selection, click the box again to select more options.
Blurry Vision Broken Glasses Burning Discharge Double Vision Dryness Excess Tearing/Watering Eye Infection/Red Eye/Pink Eye Eye Pain or Soreness Floaters or Spots in Vision Haloes Headaches None Itching Light Flashes Light Sensitivity Need New Contacts Redness Sandy/Dry/Gritty Feeling Tired Eyes Neck Pain Headaches Eye Strain Dizziness Discomfort with Computer Use
Notice of Privacy Practices* I have read or had explained to me Millennium Eye Center, Inc.’s Notice of Privacy Practices below and agree to continue my care with Millennium Eye Center, Inc. under said terms for myself and all minors listed above.
Millennium Eye Center Privacy/Security Official, James Justin
NOTICE OF PRIVACY PRACTICES - This notice was published and becomes effective on October 1, 2017
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.
YOUR RIGHTS
When it comes to your health
information, you have certain rights.
This section explains your rights and
some of our responsibilities to help you.
Get an electronic or paper copy of your
medical record:
• You can ask to see or get an
electronic or paper copy of your
medical record and other health
information we have about you.
• We will provide a copy or a
summary of your health
information, upon your request,
within 30 days. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record:
• You can ask us to correct health
information about you that you
think is incorrect or incomplete.
• We are allowed by law to say “no”
to your request, but we’ll tell you
why in writing within 60 days.
Request confidential communications:
• You can ask us to contact you in a
specific way (for example, home
or office phone) or to send mail to
a different address.
• We will say “yes” to all reasonable
requests.
Ask us to limit what we use or share:
• You can ask us not to use or
share certain health information
for treatment, payment, or our
operations.
• We are not required to agree to
your request, and we may say
“no” if it would affect your care.
• If you pay for a service or health
care item out-of-pocket in full, you
can ask us not to share that
information for the purpose of
payment or our operations with
your health insurer.
• We will say “yes” unless a law
requires us to share that
information.
Get a list of those with whom we’ve
shared information:
• You can ask for a list (accounting)
of the times we’ve shared your
health information for six years
prior to the date you ask, who we
shared it with, and why.
• We will include all the disclosures
except for those about treatment,
payment, and health care
operations, and certain other
disclosures (such as any you
asked us to make). We’ll provide
one accounting a year for free but
will charge a reasonable, costbased
fee if you ask for another
one within 12 months.
Get a copy of this privacy notice:
• You can ask for a paper copy of
this notice at any time, even if you
have agreed to receive the notice
electronically. We will provide you
with a paper copy promptly.
Choose someone to act for you:
• If you have given someone
medical power of attorney or if
someone is your legal guardian,
that person can exercise your
rights and make choices about
your health information.
• We will make sure that person
has this authority and can act for
you before we take any action.
File a complaint if you feel your rights
are violated:
• You can complain if you feel we
have violated your rights by
contacting us using the
information on page 1.
• You can file a complaint with the
U.S. Department of Health and
Human Services Office for Civil
Rights by sending a letter to 200
Independence Ave., S.W.,
Washington, D.C. 20201, or by
calling 1-877-696-6775, or by
visiting
www.hhs.gov/ocr/privacy/hipaa/co
mplaints/.
• We will not retaliate against you
for filing a complaint.
YOUR CHOICES:
For certain health information, you can
tell us your choices about what we
share. If you have a clear preference
for how we share your information in
the situations described below, talk to
us. Tell us what you want us to do, and
we will do our best to follow your
instructions.
In these cases, you have both the right
and choice to tell us to:
• Share information with your family,
close friends, or others involved in
your care.
• Share information in a disaster relief
situation.
• Contact you for fundraising efforts.
• If you are not able to tell us your
preference, for example if you are
unconscious, we may go ahead and
share your information if we believe
it is in your best interest. We may
also share your information when
needed to lessen a serious and
imminent threat to health or safety.
In these cases we NEVER share your
information UNLESS you give us
written permission:
• Marketing purposes.
• Sale of your information.
In the case of fundraising:
• We may contact you for fundraising
efforts, but you can tell us not to
contact you again.
OUR USES AND DISCLOSURES:
How do we typically use or share your
health information? We typically use or
share your health information in the
following ways.
Treat you:
• We can use your health
information and share it with other
professionals who are treating
you.
• For example, a doctor treating you
for an injury asks another doctor
about your overall health
condition.
Run our organization:
• We can use and share your health
information to run our practice,
improve your care, and contact
you when necessary.
• For example, we use health
information about you to manage
your treatment and services.
Bill for your services:
• We can use and share your health
information to bill and get payment
from health plans or other entities.
• For example, we give information
about you to your health insurance
plan so it will pay for your services.
How else can we use or share your
health information? We are allowed or
required to share your information in
other ways – usually in ways that
contribute to the public good, such as
public health and research. We have to
meet many conditions in the law before
we can share your information for these
purposes. For more information see
www.hhs.gov/ocr/privacy/hipaa/underst
anding/consumers/index.html .
Help with public health and safety
issues:
• We can share health information
about you for certain situations such
as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to
medications
• Reporting suspected abuse, neglect,
or domestic violence
• Preventing or reducing a serious
threat to anyone’s health or safety
Do Research:
• We can use or share your
information for health research.
Comply with the law.
• We will share information about you
if state or federal law requires it,
including with the Department of
Health and Human Services if it
wants to see that we’re complying
with federal privacy law.
Respond to organ and tissue donation
requests:
We can share health information about
you with organ procurement
organizations.
Work with a medical examiner or
funeral director:
We can share health information with a
coroner, medical examiner, or funeral
director when an individual dies.
Address workers’ compensation, law
enforcement, and other government
requests:
• We can use or share health
information about you:
• For workers’ compensation claims
• For law enforcement purposes or
with a law enforcement official
• With health oversight agencies for
activities authorized by law
• For special government functions
such as military, national security
and presidential protective services.
Respond to lawsuits and legal actions:
• We can share health information
about you in response to a court or
administrative order, or in response
to a subpoena.
• Our practice does not create or
manage a hospital directory, nor do
we have or maintain psychotherapy
notes at this practice.
• We adhere to all FLORIDA laws that
require greater limits on disclosures
than the federal HIPAA/HITECH
laws require.
OUR RESPONSIBILITIES:
We are required by law to maintain the
privacy and security of your protected
health information.
We will let you know promptly if a
breach occurs that may have
compromised the privacy or security of
your information.
We must follow the duties and privacy
practices described in this notice and
give you a copy of it.
We will not use or share your
information other than as described
here unless you tell us we can in
writing. If you tell us we can, you may
change your mind at any time. Let us
know in writing if you change your
mind.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understandin
g/consumers/noticepp.html .
CHANGES TO THE TERMS OF THIS
NOTICE:
We can change the terms of this notice at
any time, and the changes will apply to all
information we have about you. The new
notice will be available upon request, in our
office, and on our website.