St. Lucy’s Vision Center

NOTICE OF PRIVACY PRACTICES

William H. Stephen, O.D.

5885 Gunn Highway Tampa, Fl 33625

Phone: 813-908-0100 Fax: 813-908-0099

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.

At St. Lucy’s Vision Center, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice.

The law permits us to use or disclose your health information to those involved in your treatment. The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lens, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about you health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans, defense of legal matters; and business planning.

We routinely use your health information inside our office for these purposes without any special permission. For example, one of our staff will enter your information into our computer. We may also use your information to contact you. For example, we may send annual eye exam recall cards and birthday cards to you. We also will call to remind you about scheduled appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone. You have the right to request, in writing that we do not send you any office mailings. You also have the right to ask that we confirm your appointments at whatever telephone number you prefer.

In the case of an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release some or all of your health information when required by law.

If this practice is sold, your information will become the property of the new owner.

Except as described on the previous page, this practice will not use or disclose your health information without your prior written request. You may request in writing that we not use or disclose your health information as previously described. We will let you know if we can fulfill your request.

You have the right to know of any uses or disclosures we make with your health information beyond the described normal uses. You have the right to transfer copies of your health information to another practice or to have your prescriptions sent to another facility. A written request from you must be made, either in person, by fax or by mail before our office will release your health information or prescriptions.

You have the right to see and receive a copy of your health information, with a few exceptions. We will need a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies.

You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information.

You have the right to receive a copy of this notice. If we change the details of this notice, we will notify you of the changes in writing.

You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint.

However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Office, Micki Plourde, at (813) 908-0100.

This notice goes into effect as of April 14, 2003.