Center for Ocular Reconstruction

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.

Understanding your health record
A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examination and test results, diagnoses, treatment, and a plan for future care are recorded. This information is most often referred to as your “health or medical record,” and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professionals who may contribute to your care. Understanding what information is retained in your record and how that relates to whom, what, where, and why others may be allowed access to your health information (PHI). This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others. Use and disclosure of your PHI will follow the more stringent of State or Federal laws.

Understanding your health information rights
Your health record is the physical property of the health care practitioner or facility that compiled it but the content is about you, and therefore belongs to you. You have the right to request restrictions on certain uses and disclosures of your information, and to request amendments be made to your health record. Your rights include being able to review or obtain a paper copy of your PHI, and to receive an accounting of the disclosures we have made of your PHI for most purposes other than treatment, payment or health care operations. Other disclosures excluded are direct disclosures to yourself, family or friends involved in your care. Other than activity that already has occurred, you may revoke any further authorization to use or disclose your health information. You may also request communications of your health information be made by alternative means or to alternative locations.

Our responsibilities
This office is required to maintain the privacy of your PHI and to provide you with notice of your legal commitment and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you of we are unable to grant your requested restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations.
This office reserves the right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will notify you at the time of your next office visit. This office will post changes on our web site,, which provide information about our customer service and/or benefits.
Other than for reasons described in this notice, this office agrees not to use or disclose your health information without your authorization.

To receive additional information or report a problem
For further explanation of this notice you may contact the office manager at 301 652-9282.
If you believe your privacy rights have been violated, you have the right to file a complaint with this office by contacting the office manager or by contacting the Secretary of Health and Human Services, with no fear of retaliation by this office.

Your health information will be used for treatment, payment, and health care operations
Treatment – Information obtained by your health practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your Ocularist recording his own expectations and those of others involved in your care, such as specialty physicians.
Payment – Your health care information will be used in order to receive payment for services rendered by this office. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used.
Health Care Operations – The medical staff in this office will use your PHI to assess the care you received and the outcome of your case compared to others like it. Your information may be reviewed for risk management or quality improvement purposed in our efforts to continually improve the quality and effectiveness of the care and services we provide.

Understanding our office policy for specific disclosures
• Business Associates – Some or all of your health information may be subject to disclose through contracts for services to assist this office in providing health care. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.
• Notification – Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well being.
• Communications with Family – Using best judgment, a family member, or close personal friend, identified by you, may be given information relevant to your care.
• Marketing – This office reserves the right to contact you by mail or by telephone with appointment reminders and changes in business hours or locations.
• Worker’s Compensation – This office will release information to the extent authorized by law in matters of worker’s compensation.
• Correctional Facilities – This office will release medical information on incarcerated individuals to correctional agents or institutions for the necessary welfare of the individual or for the health and safety of other individuals. The rights outlined in this Notice of Privacy Practices will not be extended to incarcerated individuals.
• Law Enforcement – (1) Your health information will be disclosed for law enforcement purposes as required under state law or in response t a valid subpoena. (2) Provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys in the event that a staff member or business associate of this office believes in good faith that there has been unlawful conduct or violations of professional or clinical standards that may endanger one or more patients, worker, or the general public.

NOTICE OF PRIVACY PRACTICES AVAILABILITY: The terms described in this notice will be posted where registration occurs. All individuals receiving care will be given a hard copy.
This notice will be maintained and available for downloading at the following web site:

Patient Comments:

I understand that unless I specifically indicate below, my PHI will not be released to my employer. Patient initials ____

I hereby authorize the release of my PHI to my employer:


Phone #

I designate the following person as my emergency point of contact:


Phone #

I designate the following person as an alternate point of contact:

Phone #