NOTICE OF PRIVACY PRACTICES
Your Information. Your Rights. Our Responsibilities.
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.
When it comes to your health information, you have
certain rights. This section explains your rights and some
of our responsibilities to help you. You can get an
electronic or paper copy of your medical record:
You can ask to see or get an electronic or paper copy
of your medical record and other health information
we have about you. Ask us how to do this.
We will provide a copy or a summary of your health
information. We may charge a reasonable, cost-
ASK US TO CORRECT YOUR MEDICAL RECORD
You can ask us to correct health information about
you that you think is incorrect or incomplete. Ask us
how to do this.
We may say “no” to your request, but we’ll tell you
why in writing within 60 days
REQUEST CONFIDENTIAL COMMUNICATIONS
You can ask us to contact you in a specific way (for
example, home or office phone) or to send mail to a
We will say “yes” to all reasonable requests.
ASK US TO LIMIT WHAT WE USE OR SHARE
You can ask us not to use or share certain health
information for treatment, payment, or our
operations. We are not required to agree to your
request, and we may say “no” if it would affect your
If you pay for a service or health care item out-of-
pocket in full, you can ask us not to share that
information for the purpose of payment or our
operations with your health insurer. We will say “yes”
unless a law requires us to share that information.
GET A LIST OF THOSE WITH WHOM WE’VE SHARED
You can ask for a list (accounting) of the times we’ve
shared your health information for six years prior to
the date you ask, who we shared it with, and why.
We will include all the disclosures except for those
about treatment, payment, and health care
operations, and certain other disclosures (such as
any you asked us to make). We’ll provide one
accounting a year for free but will charge a
reasonable, cost-based fee if you ask for another one
within 12 months.
GET A COPY OF THIS PRIVACY NOTICE
You can ask for a paper copy of this notice at any
time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy
CHOOSE SOMEONE TO ACT FOR YOU
If you have given someone medical power of attorney
or if someone is your legal guardian, that person can
exercise your rights and make choices about your
We will make sure the person has this authority and
can act for you before we take any action.
FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE
You can complain if you feel we have violated your
rights by contacting us at 217-231-3937.
You can file a complaint with the U.S. Department of
Health and Human Services Office for Civil Rights by
sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or
We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your
choices about what we share. If you have a clear
preference for how we share your information in the
situations described below, talk to us. Tell us what you
want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell
Share information with your family, close friends, or
others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if
you are unconscious, we may go ahead and share your
information if we believe it is in your best interest. We may
also share your information when needed to lessen a
serious and imminent threat to health or safety.
In these cases we never share your information unless
you give us written permission:
Sale of your information
Most sharing of psychotherapy notes
Family Eyecare & Contact Lens Center, LLC.
In the case of fundraising:
We may contact you for fundraising efforts, but you
can tell us not to contact you again.
Our Uses and Disclosures
HOW DO WE TYPICALLY USE OR SHARE YOUR HEALTH
We typically use or share your health information in the
We can use your health information and share it with
other professionals who are treating you.
Example: A doctor treating you for an injury asks another
doctor about your overall health condition.
RUN OUR ORGANIZATION
We can use and share your health information to run our
practice, improve your care, and contact you when
Example: We use health information about you to manage
your treatment and services.
BILL FOR YOUR SERVICES
We can use and share your health information to bill and
get payment from health plans or other entities.
Example: We give information about you to your health
insurance plan so it will pay for your services.
HOW ELSE CAN WE USE OR SHARE YOUR HEALTH
We are allowed or required to share your information in
other ways – usually in ways that contribute to the public
good, such as public health and research. We have to
meet many conditions in the law before we can share
your information for these purposes. For more
HELP WITH PUBLIC HEALTH AND SAFETY ISSUES
We can share health information about you for certain
situations such as:
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic
Preventing or reducing a serious threat to anyone’s
health or safety
We can use or share your information for health research.
COMPLY WITH THE LAW
We will share information about you if state or federal
laws require it, including with the Department of Health
and Human Services if it wants to see that we’re
complying with federal privacy law.
RESPOND TO ORGAN AND TISSUE DONATION
We can share health information about you with organ
WORK WITH A MEDICAL EXAMINER OR FUNERAL
We can share health information with a coroner, medical
examiner, or funeral director when an individual dies.
ADDRESS WORKERS’ COMPENSATION, LAW
ENFORCEMENT, AND OTHER GOVERNMENT REQUESTS
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law
With health oversight agencies for activities
authorized by law
For special government functions such as military,
national security, and presidential protective services
RESPOND TO LAWSUITS AND LEGAL ACTIONS
We can share health information about you in response
to a court or administrative order, or in response to a
We are required by law to maintain the privacy and
security of your protected health information.
We will let you know promptly if a breach occurs that
may have compromised the privacy or security of
We must follow the duties and privacy practices
described in this notice and give you a copy of it.
We will not use or share your information other than
as described here unless you tell us we can in
writing. If you tell us we can, you may change your
mind at any time. Let us know in writing if you
change your mind.
FOR MORE INFORMATION SEE:
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes
will apply to all information we have about you. The new
notice will be available upon request, in our office, and on