The Optical Center of Bay Ridge

This summary notice outlines how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefuly.

We are legally obligated to maintain the privacy of protected health information, provide this notice of privacy practices and abide by the terms of this notice. We reserve the right to change or privacy practices. This notice is effective April 14, 2003.

You can review the full version of this notice by asking the receptionist for a copy of it.

1. Protected health information (PHI) is information relating to your health status or treatment as well as information relating to your health insurance, billing or payment for your health care. We only use or disclose your PHI for purposes of out treating you, verifying your insurance, billing you insurance company, processing payments from that insurance company or in our performace of other necessary business functions.

2. We will only use or disclose the minimum information necessary in order to accomplish the intended purpose. We will not disclose your PHI for any other reason without your specific authorization to do so.

3. You have the right to inspect and receive a copy of your PHI for as long as we maintain it.

4. You have the right to request restrictions on how we use or disclose your PHI.

5. You have the right to request that we amend your PHI if you believe it is inaccurate.

6. You have the right to request that we communicate with you by non-routing means or at an alternative location.

7. If we ever ask you to authorize us to use your PHI for any reason other than treatment, insurance verification, billing, payment or other necessary business functions, and you give that authorization, you have the right to revoke that authorization at a later date as well as to receive an accounting of any disclosures or uses we have amy pursuant to your authorization.

8. Any questions you may have regarding this notice or our privacy practices should be addressed to Dr. Steven Ganz, OD.

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