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.

This Notice is provided by Visualeyes Optometry, an optometry practice operated by Apikian Optometry PC, a California professional corporation, located at 4849 Van Nuys Blvd., Suite 105, Sherman Oaks, CA 91403. In this Notice, the words “we,” “us,” and “our” refer to Visualeyes Optometry, and “health information” means information that identifies you and relates to your past, present, or future health, the care we provide you, or payment for that care (also called “protected health information” or “PHI”).

Our Privacy Officer is Arra Apikian, O.D. Any written request or complaint described in this Notice should be sent to the Privacy Officer using the contact information in Section 9.

1. Our commitment to your privacy

We respect our legal obligation to keep health information that might identify you private. We are required by law to:

• Maintain the privacy and security of your health information
• Give you this Notice of our legal duties and privacy practices with respect to your health information
• Follow the terms of the Notice that is currently in effect
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your unsecured health information

This Notice describes how we may use and disclose your health information, your rights regarding that information, and how you can exercise those rights. California law, including the Confidentiality of Medical Information Act, provides additional protections for your health information; where California law is stricter than federal law, we follow California law.

2. How we may use and disclose your health information for treatment, payment, and health care operations

The most common reasons we use or disclose your health information are for treatment, payment, and health care operations. We routinely use and disclose health information within the office every day for these purposes. We do not need your specific permission to use or disclose your health information for these purposes, although you have the right to ask us to restrict such uses and disclosures (see Section 6).

Treatment. We may use and disclose your health information to provide, coordinate, and manage your eye care. Examples include:

• Setting up or changing appointments, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voicemail, text messages, or email
• Calling your name in our reception room when it is your turn to be seen
• Prescribing eyeglasses, contact lenses, or medications, and relaying that information to laboratories, suppliers, and pharmacies by phone, fax, or other electronic means, including initial prescriptions and requests from suppliers for refills
• Notifying you that your eyeglasses, contact lenses, or other ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voicemail, text messages, or email
• Referring you to another doctor or specialist for care not provided by this office, and sharing relevant information with that provider
• Obtaining copies of health information from doctors you have seen before us
• Discussing your care with you directly, or with family members or friends you have agreed or indicated may listen to information about your health
• Sending you postcards, letters, emails, or text messages, or leaving messages with those at your home who may answer the phone or on answering machines or voicemail, reminding you that it is time for continued care
• At your request, providing you with a copy of your medical records by email or other electronic transmission

Payment. We may use and disclose your health information to obtain payment for the services and products we provide. Examples include:

• Asking you about your vision or medical insurance plans or other sources of payment
• Preparing and sending bills to your insurance provider or to you
• Providing information required by third-party payors in order to secure payment for services rendered to you, including the procedures performed and the diagnosis
• Sending notices of payment due on your account to the person designated as the responsible party or head of household on your account, with fee explanations that may include procedures performed and the related diagnosis
• Collecting unpaid balances, either ourselves or through a collection agency or attorney

If you pay for a service or item in full out of pocket and ask us not to disclose information about it to your health plan, we will honor that request. See Section 6 for details.

Health care operations. We may use and disclose your health information to run our practice and make sure our patients receive quality care. Examples include:

• Financial or billing audits and internal quality assurance programs
• Participation in managed care and vision plans, and insurance audits
• Defense of legal matters and business planning
• Training staff and reviewing the performance of our doctors and employees
• Telling you about health-related products or services we offer that may be of benefit to you, as permitted by law
• Complying with requests for information from local, state, or federal government agencies, and oversight activities such as the licensing of our doctors
• Completing forms that report your vision status, at your request, to the California Department of Motor Vehicles, a school or school nurse, an employer, or an agency determining eligibility for disability status

3. Other uses and disclosures that do not require your permission

In some other limited situations, the law allows or requires us to use or disclose your health information without your specific permission. Most of these situations will never apply to you, but they could. They include:

• As required by law. When a state or federal law requires that certain health information be reported for a specific purpose.
• Public health. For public health activities, such as reporting a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices.
• Abuse, neglect, or domestic violence. Disclosures to government or law enforcement authorities about victims of suspected abuse, neglect, or domestic violence, or when someone is or is suspected to be a victim of a crime.
• Health oversight. Disclosures to agencies that oversee the health care system, such as for audits, investigations, inspections, and licensing.
• Judicial and administrative proceedings. Disclosures in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process, subject to the protections required by law.
• Law enforcement. Disclosures to law enforcement officials as required or permitted by law.
• Coroners, medical examiners, and funeral directors. Disclosures to a medical examiner or coroner to identify a deceased person or determine the cause of death, or to funeral directors to carry out their duties.
• Organ and tissue donation. Disclosures to organizations that handle organ, eye, or tissue donation and transplantation.
• Research. Uses or disclosures for health-related research, subject to the approvals and protections required by law.
• Threats to health or safety. Uses or disclosures to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public.
• Specialized government functions. Uses or disclosures for military purposes, lawful national security and intelligence activities, and protective services for the President and others.
• Workers’ compensation. Disclosures related to a workers’ compensation claim, as authorized by law.
• De-identified information and limited data sets. Disclosures of information that does not identify you, or of a “limited data set” for research, public health, or health care operations, under the conditions required by law.
• Incidental disclosures. Disclosures that are an unavoidable by-product of otherwise permitted uses and disclosures, such as another patient overhearing your name being called.
• Forms and certifications. Disclosure of information needed to complete forms related to a school vision screening, information for the California Department of Motor Vehicles, and information related to certification for occupational or recreational licenses, such as a pilot’s license.
• Business associates. Disclosures to business associates who perform services for Visualeyes Optometry (for example, optical laboratories, billing services, and the companies that host our scheduling and email systems) and who have agreed in writing to protect the privacy of your information. We also require each business associate to require any subcontractor to comply with the same privacy obligations.
• Family and friends. Unless you object, disclosure of relevant information to family members or friends who are helping you with your care, or whose presence you have allowed, which we treat as your approval for them to receive relevant information about your health. See Section 4.

4. Uses and disclosures to family, friends, and patient representatives

It is the policy of Visualeyes Optometry for our staff to take phone calls from individuals on a patient’s behalf requesting information about making or changing an appointment, or about the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Our staff will also assist individuals on a patient’s behalf in picking up or receiving delivery of eyeglasses, contact lenses, or other optical goods.

During any such telephone or in-person contact, every effort will be made to limit the conversation to only the specifics needed to complete the transaction. No information about the patient’s vision or health status will be disclosed without proper patient consent.

If you allow another person to be with you in an examination room, treatment room, dispensary, or any business area of the office while testing is performed or while your vision, health care, or account is discussed, our doctors and staff will infer that you consent to that person’s presence and to their hearing the information discussed. If you would prefer that someone not be present, simply tell us.

If you are unable to agree or object (for example, in an emergency), we may use our professional judgment to decide whether sharing relevant information with a family member or friend involved in your care is in your best interest.

5. Uses and disclosures that require your written authorization

Except as described in this Notice, we will not use or disclose your health information unless you sign a written authorization. The following uses and disclosures will be made only with your written authorization:

• Marketing. Most uses and disclosures of your health information for marketing purposes, including any marketing communication we receive payment from a third party to send you. We will not use your health information for such marketing without your written authorization.
• Sale of health information. Any disclosure that constitutes a sale of your health information. We do not sell your health information, and we will never do so without your written authorization.
• Psychotherapy notes. Most uses and disclosures of psychotherapy notes. Our practice does not generally create or maintain psychotherapy notes, but if we ever did, they would be protected in this way.
• Any other use or disclosure not described in this Notice.

The content of an authorization form is determined by federal law. A request to sign an authorization may be initiated by Visualeyes Optometry or by you. If we ask you to sign an authorization, you may decline to do so, and if you do not sign it, we may not make the use or disclosure we intended. Your treatment will not be conditioned on signing an authorization, except in the limited circumstances permitted by law.

If you sign an authorization, you may revoke it at any time by sending a written request to the Privacy Officer. Your revocation will stop any further uses or disclosures, except to the extent we have already acted in reliance on your authorization.

6. Your rights regarding your health information

The law gives you many rights regarding your health information. Unless otherwise noted, requests to exercise these rights must be made in writing to the Privacy Officer using the contact information in Section 9. We can provide you with a form for any of these requests.

Right to request restrictions. You may ask us to restrict how we use or disclose your health information for treatment (except in emergency care), payment, or health care operations, or to limit what we share with family members or friends involved in your care. We are not required to agree to your request, but if we do agree, we will honor the restriction unless the information is needed to provide you emergency treatment.

There is one restriction we must agree to: if you pay in full out of pocket for a service or item, and you ask us not to disclose information about that service or item to your health plan for purposes of payment or health care operations, we will honor that request, unless the disclosure is otherwise required by law. This restriction applies only to the encounters related to the care you want restricted.

Right to confidential communications. You may ask us to communicate with you in a confidential manner or at a specific location. Examples include contacting you only by telephone at your home, only at a particular email address, or only by mail to a particular address. We will accommodate all reasonable requests, and we will not ask you why. If a request would involve additional cost, we may ask you to agree to pay that cost.

Right to inspect and get a copy of your health information. You may ask to review or get copies of your health information, including your eye examination records, eyeglass and contact lens prescriptions, and billing records. In a very few limited situations we may deny your request, and if we do, we will tell you in writing why and how you can ask for a review of our decision. For the most part, we are happy to let you review or obtain a copy of your records. We will usually respond to your request in a few days. Under California law, we must allow you to inspect your records within five (5) working days and provide copies within fifteen (15) days of your written request. We may charge a reasonable, cost-based fee for copies, and we will tell you the cost in advance.

Right to an electronic copy. If we maintain your health information electronically, you may ask for a copy in an electronic format. We will provide it in the form and format you request if it is readily producible, and otherwise in a readable electronic form that we agree upon. The electronic formats we have approved as secure include secure email, an authorized electronic health record system, and media supplied by Visualeyes Optometry. You may also direct us in writing to send a copy of your health information to another person or organization you designate.

Right to request an amendment. You may ask us to amend or correct your health information if you believe it is incorrect or incomplete. If we agree, we will make the amendment to your record within sixty (60) days of your written request, and we will send the corrected information to you and to anyone else you tell us needs a copy. If we do not agree (for example, because we did not create the information or we believe it is accurate and complete), we will notify you in writing of our decision and the reason. You may then submit a written statement of disagreement, which we will include in your record along with any response we may wish to add.

Right to an accounting of disclosures. You may request a list of the non-routine disclosures of your health information we have made during the six (6) years before your request (or a shorter period if you wish). Routine disclosures for treatment, payment, and health care operations, disclosures you authorized, and certain other disclosures permitted by law are not included in this list. You are entitled to one such list in any twelve (12) month period without charge. For additional lists within the same twelve months, we may charge a reasonable, cost-based fee, and we will tell you the cost in advance so that you can withdraw or modify your request. We will usually respond to your written request within thirty (30) days, but we are allowed one thirty (30) day extension if we need the time to complete your request, in which case we will tell you in writing.

Right to a paper copy of this Notice. You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically. You may ask for a copy at our front desk, request one by contacting the Privacy Officer, or print it from this web page.

Right to be notified of a breach. You have the right to be notified if a breach occurs that may have compromised the privacy or security of your unsecured health information. We will notify you in writing without unreasonable delay and in no case later than sixty (60) days after we discover the breach, as required by federal and California law.

Right to choose someone to act for you. If you have given someone medical power of attorney, or if someone is your legal guardian or the parent of a minor patient, that person may exercise your rights and make choices about your health information. We will confirm that the person has this authority before taking any action.

7. Changes to this Notice

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this Notice at any time, and to make the new Notice effective for all health information we already maintain about you as well as any information we receive or create in the future. If we make a material change, we will post the new Notice in our office and on our website, and we will make copies available at the front desk on request. The effective date of the current Notice is shown at the top of this page.

You may obtain additional copies of this Notice from our business office or online at this web page.

8. Complaints

If you believe that anyone at Visualeyes Optometry has not respected the privacy of your health information, or if you have questions or concerns about this Notice or our privacy practices, you may file a complaint with our Privacy Officer using the contact information in Section 9. We will try to resolve any concern you raise, and we are happy to respond in writing.

You also have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), whether or not you have first complained to us:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-800-368-1019 (TDD: 1-800-537-7697)
Web: www.hhs.gov/ocr/privacy/hipaa/complaints/

You may also contact the California Attorney General’s Office regarding violations of California privacy law.

We will not retaliate against you, deny you treatment, or treat you differently in any way for filing a complaint, exercising any of the rights described in this Notice, or participating in any investigation.

9. Contact us

For more information about this Notice, to exercise any of your rights, or to file a complaint, contact our Privacy Officer:

Visualeyes Optometry
Attn: Arra Apikian, O.D., Privacy Officer
4849 Van Nuys Blvd., Suite 105
Sherman Oaks, CA 91403
Phone: (818) 783-8750
Fax: (818) 783-8779
Privacy inquiries: privacy@visualeyesoptom.com
General inquiries: info@visualeyesoptom.com