NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.
Please review it carefully.
This Notice of Privacy Practices (“Notice”) is provided to you pursuant to the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations (“HIPAA”). This Notice is designed to inform you of how we
may, under federal law, use or disclose your health information.
I. OUR PLEDGE TO PROTECT YOUR PRIVACY
We understand that health information about you is personal, and we are committed to protecting the privacy of your
information. As a patient treated by a health care provider affiliated with DigitalOptometrics LLC
(“DigitalOptometrics”), we maintain a record of the care you receive in a healthcare record so that we may provide you
with quality care and to comply with various legal requirements. This Notice applies to the records of your care
provided by DigitalOptometrics’ personnel.
We are required by law to:
• Maintain the privacy of your health information;
• Give you this Notice of our legal duties and privacy practices with respect to your health information;
• Notify you if you are affected by a breach of unsecured health information; and
• Follow the terms of the Notice that is currently in effect.
II. WHO WILL FOLLOW THIS NOTICE
The following people or groups will comply with this Notice:
• Any health care professional authorized to enter information into your healthcare records maintained by
• All workforce members of DigitalOptometrics.
III. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
• For Treatment: we may use or disclose your health information to provide you with optometry services.
Example: Your health information may be used by our health care practitioners involved in your care.
• For Payment: we may use or disclose your health information to obtain payment for our services. Example: Your
health information may be released to an insurance company to obtain payment for services.
• For Health Care Operations: we may use your health information for uses necessary to run our healthcare
businesses, such as to conduct quality assessment activities, train, or arrange for legal services. Example: we
may use your health information to conduct internal audits to verify proper billing procedures.
• To Business Associates: we may share your health information with “Business Associates,” as defined by HIPAA,
who provide services to or on behalf of us.
• Appointment Reminders, Test Results, Treatment Alternatives, etc.: we may use your health information to
contact you to remind you about appointments, to inform you about test results or to advise you of treatment
• Health-Related Benefits and Services: we may use your health information to advise you of health-related
benefits and services provided by us that may be of interest to you, including educational lectures, special
events and support groups.
• Individuals Involved in Your Care or Payment for Your Care: unless you tell us you object, we may use or
disclose your health information to notify a friend, family member, or legal guardian who is involved in your care
or who helps pay for your care.
• Organ and Tissue Donation: if you are an organ donor, we may release health information to organ donation
banks or organizations that handle organ or tissue procurement or transplantation.
• Fundraising Activities: we may use your health information to contact you about our fundraising efforts. Any
materials received will contain information on how to remove yourself from fundraising lists.
• As Required by Law: we will disclose your health information where required by law. Example: federal law may
require your health information to be released to an appropriate health oversight agency, public health
authority or attorney.
• Public Health and Safety: we may use and disclose your health information to prevent or control a serious
threat to the health and safety of you, others, or the public and for public health activities, such as to prevent
injury. Example: California law requires us to report birth defects and cases of communicable disease.
• Food & Drug Administration (FDA) and Health Oversight Agencies: we may disclose health information about
incidents related to food, supplements, product defects, or post-marketing surveillance to the FDA and
manufactures to enable product recalls, repairs, or replacements; and to health oversight agencies for activities
authorized by law, such as audits.
• Lawsuits/Disputes: if you are involved in a lawsuit/dispute and have not waived the physician-patient privilege,
we may disclose your health information under a court/administrative order, subpoena, or discovery request
after attempting to inform you of the request.
• Victims of Abuse, Neglect or Domestic Violence: if we reasonably believe you are a victim of abuse, neglect or
domestic violence, we may use and disclose your health information to a governmental authority, including
social service or protective services agency, authorized by law to receive reports of such abuse, neglect or
• Coroners, Medical Examiners, and Funeral Directors: we may release your health information to coroners,
medical examiners, or funeral directors to enable them to carry out their duties.
• National Security/Intelligence Activities and Protective Services: we may release your health information to
authorized local or national security or other law enforcement agencies for the protection of certain persons or
to conduct special investigations.
• Workers’ Compensation: we may use or disclose health information about you for workers’ compensation or
similar programs as authorized or required by law.
• Military/Veterans: we may disclose your health information to military authorities if you are an armed force or
• Inmates: if you are an inmate of a correctional facility or are in the custody of law enforcement, we may release
your health information to a correctional facility or law enforcement official so they may provide your health
care or protect the health and safety of you or other.
IV. OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
Other uses and disclosures of your health information not described in this Notice will be made only with your
authorization. We will obtain your written authorization for: (i) most uses and disclosures of psychotherapy notes; (ii)
most uses and disclosures of health information for marketing purposes, as defined by HIPAA; and (iii) disclosures that
constitute a sale of Protected Health Information (“PHI”), as defined by HIPAA. If you authorize us to use or disclose
your health information for another purpose, you may revoke your authorization, in writing, at any time. Your
revocation will be effective upon receipt, but will not be effective to the extent that we or others have acted in reliance
upon the authorization.
V. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the rights described below in regard to the health information that we maintain about you. You must submit a
written request to exercise any of these rights. You may obtain forms for any of these purposes by contacting the
Privacy Officer at the number or address below.
• Right to Inspect/Obtain a Copy: you have the right to inspect and get a copy of health information maintained by us
and used in decisions about your care. This right does not apply to psychotherapy notes and certain other
information. We may charge you a reasonable cost-based fee to cover copying, postage and/or preparation of a
summary. We may deny your request in certain circumstances. You may request a licensed health care professional
chosen by us to review a denial based on medical reasons; we will comply with this decision.
• Right to Amend: if you believe the health information we created for you is inaccurate or incomplete, you may ask
us to amend it in writing. We cannot delete or destroy any information already included in your medical record. You
must provide a reason for your request. We may deny your request if you ask to amend information that: (i) we did
not create (unless the person or entity that created the information is not available to make the amendment); (ii) is
not part of the health information we maintain; (iii) is not part of the information you are permitted by law to
inspect and copy; or (iv) is accurate and complete.
• Right to Accounting of Disclosures: you have the right to ask for a list or “accounting” of disclosures we have made
of your health information. We are not required to list all disclosures, such as those you authorized or disclosures
made for treatment, payment, health care operations and certain other purposes. You must state a time period,
which may not be longer than 6 years or include dates before April 14, 2003. You may obtain one accounting in a 12-
month period for free; we may charge you a reasonable fee for additional accountings of disclosures.
• Right to Request Restrictions: you have the right to request a restriction or limit how we use or disclose your health
information. You must be specific in your request for restriction. We are not required to comply with your request,
except when you request that we restrict disclosure of your health information to a health plan for a health care
item or service for which you have paid out-of-pocket in full and the disclosure is for the purpose of carrying out
payment or health care operations, and not otherwise required by law.
• Right to Request Confidential Communications: you have the right to request, in writing, that we contact you
about medical issues in a certain way, such as by mail, or at alternative locations. You must specify how or where
you wish to be contacted; we will try to accommodate reasonable requests.
• Right to a Copy of This Notice: you have the right to a paper or electronic copy of this Notice, which is posted and
available on our website.
VI. CHANGES TO OUR PRIVACY PRACTICES
We reserve the right to change our privacy practices and update this Notice accordingly. We reserve the right to make
the revised or changed Notice effective for all your health information, even if it was created prior to the change in the
Notice. Revised Notices will be posted and available on our website.
If you believe any of your privacy rights have been violated, you may file a complaint with our Privacy Officer. You may
also file a complaint with the Office for Civil Rights of the U.S. Department of Health and Human Services Rights by
sending a letter to 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201, calling 1-800-368-
1019, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not take any action against you for filing a
VI. CONTACT INFORMATION
You may contact us about our privacy practices by emailing our Privacy Officer at email@example.com.
VII. EFFECTIVE DATE
This Notice is effective as of 01/01/2021.