NOTICE OF PRIVACY PRACTICES

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.

If you have any questions about this notice, please contact :

Privacy Office
Maine Eye Center
15 Lowell Street, Portland, ME 04102
Phone number: 207-774-8277.

• Inspect and copy your health information.

• Request changes in your health information.
• Obtain a record of certain disclosures of your health information.
• Request that we communicate with you in a confidential manner.
• Request restrictions on the use and disclosure of your health information.

Your health information includes information regarding your past, present or future physical or mental health condition, the health care and services provided to you, and the past, present or future payment for your health care.

A copy of this notice is available on our website at www.maineyecenter.com. You have a right to receive a paper copy of this notice on request even if you received a copy by e-mail.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The ways we will use and disclose your health information are described below. For each use or disclosure, we will describe what we mean and give some examples. Not every use or disclosure is listed, however all the ways we can use and disclose information will fall in one of these categories.

• We may use your health information to provide you with medical treatment or services and to provide you with appointment reminders. And, we may disclose your health information to doctors, nurses, technicians, healthcare students, and other persons involved in your care. For example, your health information may be disclosed to:
  • A doctor treating you. Or, a nurse or technician who is assisting a doctor in treating you.
  • A hospital in which you are admitted as a patient.

• We may use or disclose your health information to bill or receive payment for health services you receive. For example, your health information may be disclosed:
  • To your health insurance company.
  • To your HMO.
  • To your health plan.

• We may use or disclose your health information for our operations. The uses and disclosures are necessary to manage our practice and to ensure quality of patient care. For example, your health information may be used or disclosed for the following purposes:

• To assess the quality of health care services and the development of clinical guidelines
• To evaluate competence and qualifications of health professionals.
• To obtain accreditation, credentialing or licensing of our doctors or other health care personnel.
• To conduct or arrange for medical licensure, or obtain legal or auditing services.
• To manage the business and administration of our practice, including planning and development.

• We may disclose your health information to a family member, other relative, close friend or other person you identify. Disclosures will be limited to your health information that is relevant to their involvement in your care or payment for your care.
• If you are present, your health information will be disclosed if:
  • We obtain your agreement.
  • We provide you with an opportunity to object and you do not object.
  • We reasonably assume that you do not object.

• If you are not present, or you do not have an opportunity to agree or object because of incapacity or emergency, we may make disclosures that, in our professional judgment, are in your best interest.

• We may use and disclose health information to tell you about treatment options or health-related benefits or services that may be of interest to you.

• We will disclose your health information when required by federal, state or other applicable law. And, we will disclose your health information:
  • On request of a law enforcement official if you are or are suspected to be a victim of a crime and we are unable to obtain your authorization
  • To alert a law enforcement official of your death if we suspect your death may have resulted from criminal conduct.
  • To a law enforcement official when we believe your health information is evidence of criminal conduct that has occurred on our premises.
  • To a law enforcement official, in an emergency, to report a crime, the location or victims of a crime, and the identity of the person who committed the crime.
  • To a medical examiner or coroner to identify a deceased person, determining cause of death, or other duties authorized by law.
  • To prevent or lessen a serious and imminent threat to the health or safety of a person, or the public.

• We will disclose your health information to funeral directors as necessary for them to carry out their duties.

• We will disclose your health information when needed to prevent a threat to your health and safety or the health and safety of the public or another person. Also, we will disclose your health information:
  • To a public health authority for the purpose of preventing or controlling disease, injury or disability.
  • To a public authority to report vital events such as birth or death.
  • To a public or authorized governmental authority to report child abuse or neglect.
  • To a person under the jurisdiction of the Food and Drug Administration ("FDA") to report defects or problems with FDA-regulated products, to track FDA-regulated products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance to comply with FDA requirements.
  • To a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition if we are authorized by law to notify such person.
  • To an authorized governmental authority, including a social service or protective service agency, when we believe you are the victim of abuse, neglect, or domestic violence and you agree to the disclosure, or to the extent the disclosure is required or authorized by law.

• If you are an organ donor, we may release your health information to organizations that engage in the procurement, banking, or transportation of organs, eyes or tissues for transplantation or donation.

• We may disclose your health information as authorized by and to the extent necessary to comply with laws relating to workers' compensation or similar programs that provide benefits for work-related injuries.

• We may disclose your health information:
  • To comply with a court or administrative order.
  • To comply with a subpoena, discovery request or other lawful process that is not accompanied by a court or administrative order if: (i) we receive satisfactory assurances that reasonable efforts have been made to ensure that you have been given notice of the request; or (ii) we receive satisfactory evidence that reasonable efforts have been made to secure a qualified protective order.

• We may disclose your health information to a health oversight agency for oversight activities authorized by law. These actions may include audits, civil, criminal or administrative investigations, inspections, licensure, disciplinary actions and other activities for oversight of our healthcare system.

• If you are a member of the armed forces, we may disclose your health information as required by the military. The health information of foreign military personnel may be disclosed to their appropriate foreign military authority.

• We may disclose your health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security actions. We may also disclose your health information to authorized federal officials for the provision of protective services to the President, foreign heads of state and other authorized persons.

• If you are an inmate of a state or local prison, or under custody of a law enforcement official, we may disclose your health information to the facility or law enforcement official for the following purposes:
• To provide you with health care.
• To protect your health and safety and the health and safety of other inmates.
• To protect the health and safety of officers, employees or others at the correctional facility.
• To protect the health and safety of officers and others responsible for transferring inmates.
• To protect the safety , security and good order of the correctional facility.

You have the following rights with regard to your health information in our possession or under our control:

Right to Inspect and Copy:

• You have the right to inspect and copy your health information. If you would like a copy of your health information, you should request copy request form from our office staff. To receive a copy of your health information, return the signed copy request form to our office.
• If you request a copy of your health information, you may be charged for our costs of copying and mailing. You may request our office staff give you an estimate of the costs before making your request.
• We may deny your request in certain circumstances. For example, a request to inspect or copy psychotherapy notes will be denied. If your request is denied, you may request, in writing, that the denial be reviewed. Your request to have a denial reviewed should be sent to our Privacy Officer. The review will be conducted by a licensed health care professional selected by us. The person who conducts the review will not be the same person who denied your request. We will comply with the decision made on review.

• You have the right to submit information that corrects or clarifies your health information. The information you submit will be retained with our record of your treatment. If we add a statement to your treatment record in response to your submission, we will provide you with a copy of the statement. The information you desire to submit should be sent to our Privacy Officer. The information must be in writing and should include the reasons why your health information should be corrected or clarified.

• You have the right to request a written accounting of certain disclosures we make of your health information. The accounting will include:
  • The date of each disclosure.
  • The name and, if known, the address of the person or entity receiving the disclosure.
  • A brief description of your disclosed health information .
  • A brief statement of the purpose of the disclosure.
• The disclosures for which we do not provide an accounting include:
  • Disclosures for treatment, payment or health care operations.
  • Disclosures made to you.Disclosures made to individuals involved in your care.
  • Disclosures authorized by you.
  • Disclosures for national security of intelligence purposes.
  • Disclosures to correctional institutions or law enforcement officials.
  • Disclosures made prior to April 14, 2003.
• Your request must be in writing and should be sent to our Privacy Officer. It should state the period for which you desire an accounting. The period cannot be longer than six years and cannot include any date prior to April 14, 2003.
• We may charge you for our costs of preparing the accounting. On request, our Privacy Officer will notify you of the cost.

• You have the right to restrict our use or disclosure of your health information for purposes of treatment, payment or health operations. For example, you may request that we not disclose your health information to a family member or a friend involved in your care.
• Your request to restrict the use or disclosure of your health information should be in writing and should be sent to our Privacy Officer. Your written request must state:
  • What health information you do not want used or disclosed.
  • Whether you want to limit our use, limit our disclosure or both.
  • The names of the persons or entities to whom disclosure should not be made.

• We are not required to comply with your request. If we agree, we will comply with your request except when our use or disclosure is needed to provide you with emergency treatment. We may terminate our agreement to restrict use or disclosure. Our termination will be effective only for your health information created or received after we inform you of our termination.

• You have the right to request that we communicate your health information to you at an alternate address or by alternate means. For example, you can request that we contact you only at your home. Or, you can request that we contact you only by telephone.
• We will comply with reasonable requests. And, we will not require any explanation for a request.
• Your request should be in writing and should be sent to our Privacy Officer. It should specify the alternate address to be used by us and the alternate means to be used by us to contact you.

• If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services. Your complaint should be in writing. We will not discriminate or take any other retaliatory action against you by reason of your filing a complaint or exercising any of your privacy rights.

• You may authorize us to use and disclose your health information in ways not described in this notice. Your authorization must be in writing and must comply with applicable law. You can obtain an authorization form from our Privacy Officer. You will receive a copy of each authorization you sign.
• You may revoke any authorization made by you. Once you revoke an authorization, we will no longer use or disclose your health information for the purposes that you had authorized. Your revocation will be effective except with regard to our uses and disclosures made by in reliance on your authorization.
• Your revocation must be in writing and will be effective when received by our Privacy Officer.

• There are times when individuals are legally or otherwise incapable of exercising their privacy rights, or chose to designate someone to act on their behalf. A person authorized to act on behalf of another individual is the individual's "personal representative".
• A personal representative may have broad authority to make health care decisions for an individual. Or, a personal representative's authority may be limited to specific treatment or care. For example, a legal guardian may have broad authority, while a person with an individual's limited health care power of attorney may only have authority regarding a specific treatment.
• The following identifies who will be recognized as the personal representative for a category of individuals:
  • Individual Personal Representative
  • Unemancipated minor : A parent, guardian or other person authorized by State law to make health care decisions on behalf of the minor child. See exceptions noted below.
  • Adult or emancipated minor A person with legal authority to make health care decisions on behalf of the individual. Examples: Health care power of attorney or court appointed guardia
  • Deceased individual A person with legal authority to act on behalf of the decedent's estate. Example: Personal representative
• Regardless of whether a parent is the personal representative of a minor child, under certain circumstances we are prohibited from disclosing the child's health care information to the parent. We cannot disclose a minor child's health information to a parent under the following circumstances:
  • When State or other law does not require the consent of a parent or other person before a minor can obtain a particular health care service, and the minor consents to the health service.
  • When a court determines or other law authorizes someone other than a parent to make treatment decisions for a minor.
  • When a parent agrees to a confidential relationship between the minor and our physician.
• Under certain circumstances we may chose not to recognize a person as the personal representative of our patient. For example, if we believe that a minor child or incompetent adult has been or may be subjected to domestic violence, abuse or neglect by a personal representative, or that treating a person as the minor child's or incompetent adult's personal representative could endanger the child or adult. We may choose not to treat the person as the personal representative if, in our professional judgment, doing do would not be in the best interest of the minor child or incompetent adult.

We reserve the right to change our privacy practices and this notice at any time. Any change may apply to health information that we have already created or received, as well as additional information we create or receive. If this Notice is changed, we will post a copy of the current notice in our workplace. At each appointment, you may request a copy of our current Notice of Privacy Practices.