Notice Of Privacy Practices For Protected Health Information
This notice is being provided to you as a requirement of the federal Health Insurance Portability and
Accountability Act (HIPAA). This notice describes how we may use and disclose your protected health
information to carry out treatment, payment or health care operations and for other purposes that are
permitted or required by law. It also describes your rights to access and control your protected health
information in some cases. Your "protected health information" means any written and oral health
information about you, including demographic data that can be used to identify you. This is health
information that is created in or received by your health care provider, and that relates to your past, present
or future physical health or condition.
Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made.
Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a
plan for future care or treatment. Understanding what is in your medical record and how your health
information is used helps you to ensure its accuracy, better understand who, what, when, where and why
others may access your health information, and make more informed decisions when authorizing disclosure
to others.
1 - How Medical Information About You May Be Used And Disclosed
We may use and disclose protected health information about you to provide you with medical treatment or
services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel
who are involved in taking care of you. For example, we may disclose information to people outside of our
office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.
1.1 - For Treatment
We may use and disclose protected health information about you to provide you with medical treatment or
services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel
who are involved in taking care of you. For example, we may disclose information to people outside of our
office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.
Privacy Policy
1.2 - For Payment
We may use and disclose protected health information to obtain reimbursement for the health care
provided to you. We may also use this information to obtain prior authorization for proposed treatment or to
determine whether your plan will cover the treatment. We will also share this information with our billing
service as needed to facilitate their efforts towards reimbursement from you or your insurance company.
1.3 - For Healthcare Operations
We may use and disclose protected health information to support functions of our practice related to
treatment and payment such as case management and quality assurance. In addition, we may use your
health information to evaluate staff performance, to help us decide what additional services we offer, and
other management and administrative activities.
1.4 - Appointment Reminders
We may contact you to remind you that you have an appointment or need a referral for an appointment.
1.5 - Treatment Issues
We may call you with test results, to tell you about treatment options or alternatives, or to respond to your
phone call and answer questions about your treatment.
1.6 - Health-Related Benefits and Services
We may use and disclose medical information to tell you about health-related benefits, services or medical
education classes that may be of interest to you.
1.7 - Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may disclose your protected health information to your family or friends or any other
individual identified by you when they are involved in your care or the payment for your care. We will only
disclose the protected health information directly relevant to their involvement in your care.
1.8 - Emergencies
We may use or disclose your protected health information in an emergency treatment situation. If this
happens, we will try to obtain your consent as soon as reasonably possible after the delivery of your
treatment.
1.9 - Communication Barriers
We may use or disclose your protected health information if we have attempted to
obtain consent from you but are unable to do so due to substantial communication barriers and we
determine that your consent to receive treatment is clearly inferred from the circumstances.
1.10 - Required by Law
We may use or disclose your protected health information when required by federal, state or local law. The
disclosure will be limited to the relevant requirements of the law.
1.11 - Public Health Risks
We may use or disclose your protected health information for public health reasons in order to prevent or
control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications or problems with products.
1.12 - Communicable Diseases
We may disclose your protected health information, if required by law, to a person who may have been
exposed to a communicable disease or may be at risk of contracting or spreading the disease or condition.
1.13 - Health Oversight Activities
We may disclose protected health information to federal or state agencies that oversee our activities.
1.14 - Legal Proceedings
We may disclose protected health information in response to a court or administrative order or in response
to a subpoena, discovery request or other lawful process.
1.15 - Law Enforcement
We may release protected health information if asked to do so by a law enforcement official in response to
a court order, subpoena, warrant, summons or similar process subject to all applicable legal requirements.
1.16 - Workers Compensation
We may disclose your protected health information as authorized to comply with workers' compensation
laws and other similar legally established programs.
1.17 - Military Activity and National Security
If you are, or were, a member of the armed forces or part of the National Security and Intelligence
communities we may be required by military command or other government authorities to release health
information about you. We may also release information about foreign military personnel to the appropriate
foreign military authority.
1.18 - Business Associates
There may be some services provided in our organization through contracts with Business Associates.
Examples include our billing services, answering services, web services, etc. When these services are
contracted, we may disclose some of your protected health information to our Business Associate so that
they can perform their job. To protect your health information, however, we require the Business Associate
to appropriately safeguard your information.
1.19 - Other Uses and Disclosures of Health Information
Other uses and disclosures of your protected health information will be made only with your written
authorization unless otherwise permitted or required by law as described above. You may revoke this
authorization at any time in writing, except to the extent that action has already been taken in reliance on
the use or disclosure indicated on the authorization.
2 - Your Health Information Rights
You have the right to inspect and obtain a copy of your protected health information. This means you may
inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply.
This request must be made in writing.
2.1 - Right To Inspect And Copy Your Protected Health Information
You have the right to inspect and obtain a copy of your protected health information. This means you may
inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply.
This request must be made in writing.
2.2 - Right To Request A Restriction On Uses And Disclosures Of Your Protected Health Information
You have the right to request a restriction on your protected health information. This means you may ask us
to restrict or limit disclosure of any part of your protected health information. You may also request that any
part of your protected health information not be disclosed to family members or friends who may be
involved in your care or payment for your care. You must state the specific restriction requested and to
whom you want the restriction to apply. However, this request is subject to our approval. If the physician
believes it is in your best interest to permit use and disclosure of your information, it will not be restricted. If
the physician does agree to the requested restriction, we may not use or disclose your protected health
information unless it is needed to provide emergency treatment.
2.3 - Right To Request To Receive Confidential Communications
You have the right to request to receive confidential communications from us by alternative means or at an
alternative location. We will accommodate reasonable requests. You must make this request in writing and
your request must specify how or where you wish to be contacted. We will not ask you the reason for your
request. We will also send our email newsletter to you at no additional cost. Please notify us immediately
if you would prefer not to receive it.
2.4 - Right To Request Amendments To Your Protected Health Information
You have the right to request a correction to your protected health information. This means you may
request an amendment of your medical record if you believe the health information we have about you is
incorrect or incomplete. You must make this request in writing. Forms are available for this purpose and can
be obtained from us. We may deny your request for an amendment if we feel it is inaccurate, or if the
amendment you are requesting is part of the record that was not created by us. If we deny your request for
amendment, you have the right to have your request and our denial added to your medical record.
2.5 - Right To Receive An Accounting
You have the right to receive an accounting of disclosures of your protected health information. This right
applies to disclosures for purposes other than treatment, payment or healthcare operation, or for disclosures
that occurred prior to April 14, 2003. You must make this request in writing and this request must include a
time frame, which may not be longer than 6 years or may not include dates prior to April 14, 2003.
2.6 - Right To Obtain A Paper Copy Of This Notice
You have the right to obtain a paper copy of this notice from us.
2.7 - Right To Register A Complaint
You have the right to register a complaint if you feel your privacy rights have been violated. If you believe
your privacy rights have been violated, you may file a complaint with our office. You may also file a
complaint with the Secretary of the Department of Health & Human Services. You will not be penalized for
filing a complaint.
3 - Changes To This Notice
We reserve the right to change this notice and to make the revised or changed notice effective for medical
information we already have about you as well as any information we receive in the future. We will post a
summary of the current notice in the office with its effective date at the top. You are entitled to a copy of
the notice currently in effect. This notice will be posted on our website.
4 - Contacting Our Privacy Officer
Amandip Sappal, O.D.
Tel (954) 252-8885
Fax (954)252-8882
15651 Sheridan St
Suite 1000
Davie,FL 33331
5 - Effective Date
This notice is effective June 30, 2005.
Optical Policies
Ophthalmic Frames = Ophthalmic frames may be returned within 30 days if they are in “re-sellable”
condition. “Re-sellable” means that they are free of any defects, scratches, blemishes, hairs, oils, breaks,
deformities, or chips. It is the patient’s responsibility to ask about a frame’s warranty. Discount frames have a
maximum 60 day warranty. Sheridan Eye Care ultimately reserves the right to determine if a partial or full
refund is given or not.
Opthalmic Lenses = Ophthalmic lenses are considered custom orders made by an outside lab; therefore,
they can not be refunded. If there is a prescription error, lens performance issue, or progressive non-adapt,
every appropriate measure will be taken by Sheridan Eye Care to remedy the problem at no cost to the
patient.
Services = All fees for services are due at the time services are rendered.
Sunglasses = No refunds are allowed on non-prescription sunglasses. All sales are considered final.
This notice is being provided to you as a requirement of the federal Health Insurance Portability and
Accountability Act (HIPAA). This notice describes how we may use and disclose your protected health
information to carry out treatment, payment or health care operations and for other purposes that are
permitted or required by law. It also describes your rights to access and control your protected health
information in some cases. Your "protected health information" means any written and oral health
information about you, including demographic data that can be used to identify you. This is health
information that is created in or received by your health care provider, and that relates to your past, present
or future physical health or condition.
Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made.
Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a
plan for future care or treatment. Understanding what is in your medical record and how your health
information is used helps you to ensure its accuracy, better understand who, what, when, where and why
others may access your health information, and make more informed decisions when authorizing disclosure
to others.
1 - How Medical Information About You May Be Used And Disclosed
We may use and disclose protected health information about you to provide you with medical treatment or
services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel
who are involved in taking care of you. For example, we may disclose information to people outside of our
office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.
1.1 - For Treatment
We may use and disclose protected health information about you to provide you with medical treatment or
services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel
who are involved in taking care of you. For example, we may disclose information to people outside of our
office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.
Privacy Policy
1.2 - For Payment
We may use and disclose protected health information to obtain reimbursement for the health care
provided to you. We may also use this information to obtain prior authorization for proposed treatment or to
determine whether your plan will cover the treatment. We will also share this information with our billing
service as needed to facilitate their efforts towards reimbursement from you or your insurance company.
1.3 - For Healthcare Operations
We may use and disclose protected health information to support functions of our practice related to
treatment and payment such as case management and quality assurance. In addition, we may use your
health information to evaluate staff performance, to help us decide what additional services we offer, and
other management and administrative activities.
1.4 - Appointment Reminders
We may contact you to remind you that you have an appointment or need a referral for an appointment.
1.5 - Treatment Issues
We may call you with test results, to tell you about treatment options or alternatives, or to respond to your
phone call and answer questions about your treatment.
1.6 - Health-Related Benefits and Services
We may use and disclose medical information to tell you about health-related benefits, services or medical
education classes that may be of interest to you.
1.7 - Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may disclose your protected health information to your family or friends or any other
individual identified by you when they are involved in your care or the payment for your care. We will only
disclose the protected health information directly relevant to their involvement in your care.
1.8 - Emergencies
We may use or disclose your protected health information in an emergency treatment situation. If this
happens, we will try to obtain your consent as soon as reasonably possible after the delivery of your
treatment.
1.9 - Communication Barriers
We may use or disclose your protected health information if we have attempted to
obtain consent from you but are unable to do so due to substantial communication barriers and we
determine that your consent to receive treatment is clearly inferred from the circumstances.
1.10 - Required by Law
We may use or disclose your protected health information when required by federal, state or local law. The
disclosure will be limited to the relevant requirements of the law.
1.11 - Public Health Risks
We may use or disclose your protected health information for public health reasons in order to prevent or
control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications or problems with products.
1.12 - Communicable Diseases
We may disclose your protected health information, if required by law, to a person who may have been
exposed to a communicable disease or may be at risk of contracting or spreading the disease or condition.
1.13 - Health Oversight Activities
We may disclose protected health information to federal or state agencies that oversee our activities.
1.14 - Legal Proceedings
We may disclose protected health information in response to a court or administrative order or in response
to a subpoena, discovery request or other lawful process.
1.15 - Law Enforcement
We may release protected health information if asked to do so by a law enforcement official in response to
a court order, subpoena, warrant, summons or similar process subject to all applicable legal requirements.
1.16 - Workers Compensation
We may disclose your protected health information as authorized to comply with workers' compensation
laws and other similar legally established programs.
1.17 - Military Activity and National Security
If you are, or were, a member of the armed forces or part of the National Security and Intelligence
communities we may be required by military command or other government authorities to release health
information about you. We may also release information about foreign military personnel to the appropriate
foreign military authority.
1.18 - Business Associates
There may be some services provided in our organization through contracts with Business Associates.
Examples include our billing services, answering services, web services, etc. When these services are
contracted, we may disclose some of your protected health information to our Business Associate so that
they can perform their job. To protect your health information, however, we require the Business Associate
to appropriately safeguard your information.
1.19 - Other Uses and Disclosures of Health Information
Other uses and disclosures of your protected health information will be made only with your written
authorization unless otherwise permitted or required by law as described above. You may revoke this
authorization at any time in writing, except to the extent that action has already been taken in reliance on
the use or disclosure indicated on the authorization.
2 - Your Health Information Rights
You have the right to inspect and obtain a copy of your protected health information. This means you may
inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply.
This request must be made in writing.
2.1 - Right To Inspect And Copy Your Protected Health Information
You have the right to inspect and obtain a copy of your protected health information. This means you may
inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply.
This request must be made in writing.
2.2 - Right To Request A Restriction On Uses And Disclosures Of Your Protected Health Information
You have the right to request a restriction on your protected health information. This means you may ask us
to restrict or limit disclosure of any part of your protected health information. You may also request that any
part of your protected health information not be disclosed to family members or friends who may be
involved in your care or payment for your care. You must state the specific restriction requested and to
whom you want the restriction to apply. However, this request is subject to our approval. If the physician
believes it is in your best interest to permit use and disclosure of your information, it will not be restricted. If
the physician does agree to the requested restriction, we may not use or disclose your protected health
information unless it is needed to provide emergency treatment.
2.3 - Right To Request To Receive Confidential Communications
You have the right to request to receive confidential communications from us by alternative means or at an
alternative location. We will accommodate reasonable requests. You must make this request in writing and
your request must specify how or where you wish to be contacted. We will not ask you the reason for your
request. We will also send our email newsletter to you at no additional cost. Please notify us immediately
if you would prefer not to receive it.
2.4 - Right To Request Amendments To Your Protected Health Information
You have the right to request a correction to your protected health information. This means you may
request an amendment of your medical record if you believe the health information we have about you is
incorrect or incomplete. You must make this request in writing. Forms are available for this purpose and can
be obtained from us. We may deny your request for an amendment if we feel it is inaccurate, or if the
amendment you are requesting is part of the record that was not created by us. If we deny your request for
amendment, you have the right to have your request and our denial added to your medical record.
2.5 - Right To Receive An Accounting
You have the right to receive an accounting of disclosures of your protected health information. This right
applies to disclosures for purposes other than treatment, payment or healthcare operation, or for disclosures
that occurred prior to April 14, 2003. You must make this request in writing and this request must include a
time frame, which may not be longer than 6 years or may not include dates prior to April 14, 2003.
2.6 - Right To Obtain A Paper Copy Of This Notice
You have the right to obtain a paper copy of this notice from us.
2.7 - Right To Register A Complaint
You have the right to register a complaint if you feel your privacy rights have been violated. If you believe
your privacy rights have been violated, you may file a complaint with our office. You may also file a
complaint with the Secretary of the Department of Health & Human Services. You will not be penalized for
filing a complaint.
3 - Changes To This Notice
We reserve the right to change this notice and to make the revised or changed notice effective for medical
information we already have about you as well as any information we receive in the future. We will post a
summary of the current notice in the office with its effective date at the top. You are entitled to a copy of
the notice currently in effect. This notice will be posted on our website.
4 - Contacting Our Privacy Officer
Amandip Sappal, O.D.
Tel (954) 252-8885
Fax (954)252-8882
15651 Sheridan St
Suite 1000
Davie,FL 33331
5 - Effective Date
This notice is effective June 30, 2005.
Optical Policies
Ophthalmic Frames = Ophthalmic frames may be returned within 30 days if they are in “re-sellable”
condition. “Re-sellable” means that they are free of any defects, scratches, blemishes, hairs, oils, breaks,
deformities, or chips. It is the patient’s responsibility to ask about a frame’s warranty. Discount frames have a
maximum 60 day warranty. Sheridan Eye Care ultimately reserves the right to determine if a partial or full
refund is given or not.
Opthalmic Lenses = Ophthalmic lenses are considered custom orders made by an outside lab; therefore,
they can not be refunded. If there is a prescription error, lens performance issue, or progressive non-adapt,
every appropriate measure will be taken by Sheridan Eye Care to remedy the problem at no cost to the
patient.
Services = All fees for services are due at the time services are rendered.
Sunglasses = No refunds are allowed on non-prescription sunglasses. All sales are considered final.
Privacy Policy
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| SheridaN EYE CARE |
| 15651 Sheridan St./Suite 1000 Davie, FL 33331 (954) 252-8885 (Next to Muvico 24 Theaters) |
| SheridaN EYE CARE |
| 9840 W. Sample Road Coral Springs, FL 33065 (954)755-3750 (Next to Runyon's & Wings Plus) |
Pembroke Pines/South Broward (954) 252-8885
Coral Springs/North Broward (954) 755-3750
Coral Springs/North Broward (954) 755-3750