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.