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Medical Information Release Form
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Your Rights – Our Responsibilities
Privacy Practices
Notice of Behavioral Standards
Valley EyeCare Center Medical Associates Notice of Privacy Practices Effective Date: April 14, 2003THIS 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.
At Valley EyeCare Center we have always kept your health information secure and confidential. A new law requires us to continue those practices, to give you this notice, and to follow its terms. We may use or disclose your information for treatment, payment and healthcare operations.We may use and disclose medical information to contact and remind you about appointments. If you are not available, we may leave this information on an answering machine or in a message left with the person answering the phone. In an emergency, we may disclose your health information to a family member or other person responsible for your care.We may release some or all of your health information when required by law. We may disclose your health information as necessary to comply with worker’s compensation laws. If this practice is sold, your information will become the property of the new owner. Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will inform you if your request can be fulfilled and reasonable fees may be charged for special accommodations. You have the right to inspect, amend, supplement, or retain copies of your health information within the limits of the law. Your request must be in writing, a reasonable fee may be charged, and we will respond within the time allowed by California law. You have the right to receive a copy of this notice. If information in this notice is changed, you will be informed in writing. Please contact our Privacy Officer, Lori Gagnon, if you have any questions or would like further information. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Dept. of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.