HIPAA NOTICE OF PRIVACY PRACTICES 
Effective Date (January 1, 2004)

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: Pacific Eye 
Associates at: (415)923-3007.        . 

This notice describes the privacy practices at our office. 

We are required by law to:

* Maintain the privacy of protected health information
* Give you this notice of our legal duties and privacy 
  practices regarding your health information
* Follow the terms of the notice currently in effect.

How we may use and disclose your health information:

The following descriptions are the ways we may use and 
disclose your health information. Except for the following 
purposes we will use and disclose your health information 
only with your written permission. You may revoke such 
permission at any time by writing to your physician at 
Pacific Eye Associates. 

Treatment: We may use and disclose your health 
information for your treatment and to provide you with 
treatment-related health care services. For example, we 
may 
disclose your health information to doctors, nurses, 
technicians, or other personnel, including people outside 
our office, who are involved in your medical care and need 
the information to provide you with medical care.

Payment: We may use and disclose your health 
information so that others or we may bill and receive 
payment from you, an insurance company, or a third party 
for the treatment and services you received. For example, 
we may give information to your health plan so that they 
will pay for your treatment.

Health Care Operations: We may use and disclose 
your 
health information to evaluate and improve our medical 
care 
and to operate and manage our office. For example, we may 
use and disclose information to a peer review organization 
or a health plan that is evaluating our care. We may also 
share information with others that have a relationship 
with 
you for their health care operation activities.

Appointment Reminders, Treatment Alternatives, and Health-
Related Benefits and Services. We may use and disclose 
your 
health information to contact you and remind you of your 
appointment, to tell you about treatment alternatives or 
health-related benefits and services you could use.

Individuals Involved in Your Care or Payment for Your 
Care. 
When appropriate, we may share your health information 
with 
a person involved in, or paying for, your care (such as 
your family or a close friend). We may notify your family 
about your location or condition or disclose such 
information to an entity assisting in disaster relief.

Research: We may use and disclose your health 
information 
for research. For example, a research project may involve 
comparing the health of patients who received one 
treatment 
to those who received another for the same condition. 
Before we do so, the project needs to go through a special 
approval process. Even without special approval, we may 
permit researchers to look at records to help identify 
patients who may be included in their research, as long as 
they do not remove or copy any of your health information.

As Required by Law: We will disclose your health 
information when required to do so by international, 
federal, state or local law.

To Avert a Serious Threat to Health or Safety: We 
may use and disclose your health information when 
necessary 
to prevent a serious threat to the health and safety of 
you, another person, or the public. Disclosures will be 
made only to someone who can prevent the threat.

Business Associates: We may disclose your health 
information to our business associates that perform 
functions on our behalf or provide us with services if 
necessary. For example, we may use another company to 
perform billing services on our behalf. All of our 
business 
associates are obligated to protect the privacy of your 
information and are not allowed to use or disclose the 
information for any other purpose than appears in their 
contract with us.

Military and Veterans: If you are a member of the 
armed forces, we may release your health information as 
required by military command authorities. If you are a 
member of a foreign military we may release your health 
information to the foreign military command authority.

Worker's Compensation: We may release your health 
information for worker's compensation or similar programs 
that provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose your health 
information for public health activities to prevent or 
control disease, injury or disability. We may use your 
health information in reporting births or deaths, 
suspected 
child abuse or neglect, medication reactions or product 
malfunctions or injuries, and product recall 
notifications. 
We may use your health information to notify someone who 
may have been exposed to a disease or may be at risk for 
contracting or spreading a disease or condition. If we are 
concerned that a patient may have been a victim of abuse, 
neglect, or domestic violence we may ask your permission 
to 
make a disclosure to an appropriate government authority. 
We will make that disclosure only when you agree or when 
required or authorized to do so by law.

Health Oversight Activities: We may disclose your 
health information to a health oversight agency for 
activities authorized by law. These may include audits, 
investigations, inspections, and licensure. These 
activities are necessary to for the government to monitor 
the health care system, government programs, and 
compliance 
with civil rights laws.

Lawsuits and Disputes: If you are involved in a 
lawsuit or dispute, we may disclose your health 
information 
in response to a court or administrative order. We may 
disclose your health information in response to a 
subpoena, 
discovery request, or other lawful process by someone else 
involved in the dispute, but only if efforts have been 
made 
to tell you about the request or to obtain an order 
protecting the information requested.

Law Enforcement: We may release your health 
information request by law enforcement official if 1) 
there 
is a court order, subpoena, warrant, summons or similar 
process; 2) if the request is limited to information 
needed 
to identify or locate a suspect, fugitive, material 
witness, or missing person; 3) the information is about 
the 
victim of a crime even if, under certain very limited 
circumstances, we are unable to obtain your agreement; 4) 
the information is about a death that may be the result of 
criminal conduct; 5) the information is relevant to 
criminal conduct on our premises; and 6) it is needed in 
an 
emergency to report a crime, the location of a crime or 
victims, or the identity, description, or location of the 
person who may have committed the crime.

Coroners, Medical Examiners, and Funeral Directors: 
We may release your health information to a coroner, 
medical examiner, or funeral director to identify a 
deceased person or cause of death, or other similar 
circumstance. 

National Security and Intelligence Activities: We 
may disclose your health information to authorized federal 
officials for intelligence and other national security 
activities authorized by law.

Inmates or Individuals in Custody: If you are an 
inmate of a correctional institution or in custody we may 
disclose your information 1) for the institution to 
provide 
you with health care, 2) to protect your health and safety 
or that of others, and 3) for the safety and security of 
the institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Inspect and Copy: You have the right to 
inspect and copy your medical and billing records by 
written request to your physician at Pacific Eye 
Associates.

Right to Amend: You have the right to request an 
amendment to your records by written request to your 
physician at Pacific Eye Associates.

Right to an Accounting Of Disclosures: You have a 
right to an accounting of certain disclosures by written 
request to your physician at Pacific Eye Associates.

Right to Request Restrictions: You have the right 
to 
request restriction or limitation on your health 
information used for treatment, payment or health care 
operations. You may request us to limit disclosure to 
someone involved in your care or in payment for your care 
(such as a spouse) by written request to your physician at 
Pacific Eye Associates.  We are not required to agree with 
your request, but we will try to comply. 

Right to Request Confidential Communication: You 
have the right to request that we communicate with you 
about medical matters in a certain way or at a certain 
location. You can ask, for example, that we contact you 
only by mail or at work. Your written request must specify 
how or where you wish to be contacted and be addressed to 
Pacific Eye Associates. We will accommodate reasonable 
requests.

CHANGES TO THIS NOTICE

We may change this notice and make it effective for 
medical 
information we already have about you as well as new 
information. The current notice will be posted and 
available at all times. You have a right to request a 
paper 
copy of the current notice at any visit or by written 
request to Pacific Eye Associates.

PACIFIC EYE ASSOCIATES
2100 Webster Street, Suite 214
San Francisco, CA, 94115
(415) 923-3007 
eyeservices@pacificeye.com