Your "health information," for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as "health information" in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information. We must follow the duties and privacy practices described in this notice and give you a copy of it.

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us.

Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

• when a state or federal law mandates that certain health information be reported for a specific purpose;

• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;

• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;

• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;

• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;

• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;

• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;

• uses or disclosures for health related research;

• uses and disclosures to prevent a serious threat to health or safety;

• uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;

• disclosures of de-identified information;

• disclosures relating to worker’s compensation programs;

• disclosures of a "limited data set" for , public health, or health care operations;

• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;

• disclosures to "business associates" and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA;

Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care with your written consent. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for healthcare prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION

The following are some specific uses and disclosures that we will never share your health information without your authorization:

Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also include consent to such payment.

Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so.

Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

• Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.

• You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.

• We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.

• We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization.

However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

YOUR INDIVIDUAL RIGHTS

When it comes to your health information, you have certain rights. You have many rights concerning the confidentiality of your health information. This section explains your rights and some of our responsibilities to help you. You have the right:

• To request 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, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

• To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.

• To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. 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 these requests, and we may say “no,” if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment. 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. To request restrictions, please send a written request to us at the address below.

• To receive confidential communications of health information about you in any manner other than described in our authorizationrequest form. You must make such requests in writing to the address below. You can ask us to contact you in a specific way (for example: home, office, or cell phone) or to send mail to a different address. We will say “yes” to all reasonable requests. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.

• To amend health information. If you feel that health information, we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information:

  • was not created by us, unless the person that created the information is no longer

  • available to make the amendment,

  • is not part of the health information kept by or for us,

  • is not part of the information you would be permitted to inspect or copy, oro is accurate and complete.

• To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically).

• To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person, the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.

If you are not able to tell us your preference, for example if you are unconscious, we may 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.

SMS/TEXT MESSAGING DISCLOSURE

By providing your mobile phone number and opting in to receive text messages from The Eye Collective, PLLC, you agree to receive text messages from The Eye Collective Patient Communication Program. These messages may include:

• Appointment reminders

• Appointment confirmations or scheduling updates

• Order status notifications for eyewear or contact lenses

• Patient care communications related to your visit

• Occasional office notifications (such as closures or urgent updates)

These messages are intended to assist in coordinating your care with The Eye Collective, PLLC.

We do not sell, rent, or share your mobile phone number with third parties for marketing purposes.

Contact Person: For all questions, requests or for further information related to the privacy of your health information, please send inquiries to: info@eyecollectivevision.com or call us at 407-987-4050. Please mail all written requests to:

The Eye Collective, PLLC

354 W Fairbanks Ave

Suite 354

Winter Park, FL 32789

Complaints: If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to 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 visiting: https://www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you if you make a complaint. If you want to complain to us directly, please send a written complaint to the office at the email or physical practice address shown above. If you prefer, you can discuss your complaint in person or by phone.

Changes to This Notice: We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.

Get a Copy of This Privacy Notice: You can ask for a paper copy of this notice at any time, even if you agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose Someone to Act For You: If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Our Responsibility: We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Please tell us in writing through the above methods if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.