CARROLLTON FAMILY VISION PRACTICE

740 Bankhead Highway Carrollton, GA 30117 Voice (770) 832-2815 Fax (770) 832-0176

PATIENT PRIVACY NOTICE

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.

The office of Dr. Paul H. McRae (referred to hereafter as the or this ?office?) is committed to protecting your personal medical information. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care and complies with this office?s medical record retention requirements. This notice applies to the medical records maintained by this office and it specifically details the ways in which your medical information may be used and disclosed to third parties. This notice also details your individual rights regarding your medical records.

1. This office may use and/or disclose your medical information consistent with a valid consent granted by you for the purpose of: a. Treatment -In order to provide you with the healthcare you require, this office will provide your medical information to those healthcare professionals, whether on this office?s staff or not, directly involved in your care so that they may understand your medical condition and needs. For example, a physician treating you for headaches may need to know about the results of your latest examination by our office.

b. Payment -In order to get paid for services provided, this office will provide your medical information, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, this office may need to provide the Medicare program with information about the services you received so that this office can be properly reimbursed. This office may also need to tell your insurance plan about a treatment you are going to receive so that it can be determined whether or not your plan will cover the treatment.

c. Healthcare Operations -In order to gain an overall view of various elements of this office?s operations, individual medical information may be collected, compiled, and disseminated. For example, this office may utilize your medical information in order to evaluate the performance of our personnel in providing care to you. 2. This office may use and/or disclose your medical information, without a written consent, in the following instances: a. De-identified Information -Information that is not individually identifiable for that has had all personally identifying information removed, in accordance with applicable laws, may be freely discussed by this office. b. Business Associate -If this office satisfactory written assurance from the business associate, in accordance with applicable laws, that the business associate will appropriately safeguard the protected information; c. Personal Representative -If under applicable Georgia law a person has the authority to represent you in making decisions related to your health care, information may be disclosed to that person without your written consent; d. Emergency Situations i. For the purpose of obtaining or rendering emergency treatment to you, if the office attempts to obtain consent but is unable to do so; ii. To a public or private entity authorized by law or its charter to assist in disaster relief efforts, or the purpose of coordinatin g your care with such entities in an emergency situation; e. Communication Barriers -If, due to substantial communication barriers or inability to communicate, this office has been unable to obtain consent and this office determines, in the exercise of its professional judgement, that your consent to receive treatment is clearly inferred from the circumstances;

f. Directory -In order to maintain a directory of individuals in this office, their location, their condition in non-specific general terms, and their religious affiliation. This information can be made available in its entirety to members of the clergy and, except for religious affiliation, to anyone asking for you by name. g. Involvement in Care or Payment -In accordance with applicable laws, disclosure may be made to your family member, other relatives, close personal friends and/or any other person identified by you, of such information that is relevant to the person?s involvement with your care or payment related to your health care; h. Notification -In order to notify or assist in the notification of a family member, a personal representative or another person responsible for your care of your location or general condition; i. Required by Law -When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law; j. Criminal Conduct -To a law enforcement official, that this office believes in good faith contributes evidence of criminal conduct that occurred on the office premises; k. Organ Procurement Organizations -Or other entity engaged in the procurement, banking or transportation of organs for the purpose of facilitating organ, eye or tissue donation and transplantation; l. Threat to Health and/or Safety -If it is necessary to prevent or lessen a serious and imminent threat to the health and /or safety of a person or the public, in accordance with applicable laws; m.Appointment Reminders, Treatment Alternatives and Health Related Benefits -In order to provide you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you;

n. Military and Veterans -If you are a member of the armed forces, as required by military command authorities;

o. Worker?s Compensation -In order to provide information about you to worker?s compensation programs designed to provide benefits for work related injuries; p. Public Health Risks -In order to prevent or control disease, injury and disability and to report child abuse or neglect; q. Health Oversight Activities -In order to provide information to a health oversight agency, such as the Georgia Department of Community Health, for activities authorized by law, including inspections, investigations, audits and licensure; r. Lawsuits and Disputes -In order to comply with a court or administrative order in connection with a lawsuit or dispute; s. Coroner, Medical Examiners and Funeral Directors -In order to provide information to a coroner, medical examiner or funeral director for purposes of identification of an individual, the determination of the cause of death and for burial purposes; t. National Security and Intelligence Activities -In order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law. 3. Other uses and/or disclosures will be made only with your written authorization and you may revoke any authorization as set forth in this notice. 4. Your Individual Rights -You have the right to: a. Revoke any authorization and/or consent, in writing, at any time -To request a revocation, please submit a written request to the office?s Privacy Officer, as set forth in Section 4(i) below; b. Request restrictions on certain uses and/or disclosures as provided by law; however, this office is not obligated to agree to any requested restrictions -To request restrictions, please submit a written request to this office?s Privacy Officer, as set forth in Section 4(i) below. In this written request you must inform this office what information you want to limit, whether you want to limit this office?s use or disclosure, or both, and to whom you want the limits to apply. If this office agrees with

your request, we will comply with the request unless the information is needed to provide you emergency treatment;

c. Receive confidential communications of protected health information as required by law -To request confidential communications, you must make your request in writing to this office?s Privacy Officer, as set forth in Section 4(i) below. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted. d. Inspect and copy protected health information as provided by law -This right includes access to medical and billing records. To inspect and copy health information, please submit a written request to the office?s Privacy Officer, as set forth in Section 4(i) below. This office can charge you a fee for the costs of copying, mailing or other supplies associated with your request. This office may deny you access to medical information but you have the right to have this denial reviewed as will be set forth more fully in the written denial notice; e. Amend incorrect or incomplete protected information as provided by law -To request an amendment, please submit a written request to the office?s Privacy Officer, as set forth in Section 4(i) below. You must provide a reason that supports your request for the amendment(s). This office may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by this office (unless the individual or entity that created the information is no longer available), if the information is not part of the medical information maintained by this office, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete; f. Receive an accounting of disclosures (but not the uses) of protected information as provided by law -To request an accounting, please submit a written request to this office?s Privacy Officer, as set forth in Section 4(i) below. The request must state a time period that may not be longer than 6 years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free but this office may charge you for the costs of providing additional lists. This office will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred;

g. To receive a paper copy of this notice from this office upon request to this office?s Privacy Officer, as set forth in Section 4(i) below; h. To complain to this office or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint, please contact this office?s Privacy Officer, as set forth in Section 4(i) below. All complaints must be in writing; i. To obtain more information on, or have our questions about your rights answered, you may contact this office?s Privacy Officer, Faith Smith at (770) 832-2815, or via e-mail at cfvp1@hotmail.com 5. Office Rights & Requirements - This office: a. Is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected information; b. Is required to abide by the terms of this notice; c. Reserves the right to change the terms of this notice and to make the new notice provisions effective for all protected information that it maintains. d. Will: i. Distribute any revised notice at a Resident Council Meeting prior to implementation; ii. Give to you, and you will be required to sign a receipt for, any revised notice. e. Will not retaliate against you for filing a complaint. 6. This original notice is in effect as of April 14, 2003.