NOTICE OF PRIVACY PRACTICE

Fairway Eye Center Inc.
3414 Shawnee Mission Pkwy, Fairway, KS 66205 (913) 362-2323
1528 NE 96th ST Suite A, Liberty, MO 64068 (816) 781-5444
508 Cherokee St. Leavenworth, KS 66048 1(913)682-2020

THIS NOTICE DESCRIBE HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISLCOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with the notice of is legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this notice. How We May Use or Disclose Your Health Information We will protect the privacy of your health information. The law permits us to use or disclose your health information for the following purpose:

• Treatment, Payment, and Regular Health Care Operation - Information obtained by us will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request.
• As and When required by law- We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), Judicial and Administrative, Deceased Person Information., Worker Compensations programs, Food & Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the military or a veteran of the armed forces when requested, of if you become an inmate in a correctional facility.
• Personal Communication- We may contact you to provide appointments reminders, annual eye examination cards, and other information about treatments alternatives or other health-related benefits and service that may be of interest to you as well as communicate with individuals involved in your care or payment for your care.
• Disclosures to Our Business Associates- There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose health information about you to our business associates so that they can perform the job we have asked them to do and bill you and your third-party payer for service rendered. To protect your health information, we require the business associates to appropriately safeguard the health information.
• Victims /Abuse, Neglect, or Domestic Violence- We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

Marketing Communication. We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatments, care or alternative treatments, or provides without authorization.

When We May ot Use or Disclose Your Health Information Except as described in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

You Have the Following Rights With Respect To Your Health Information

• You have the right to request restrictions on certain uses and disclosures of your health information. To make sure a request, you must complete the Restriction of the Use of Patient Information Form. We are not required to agree to the restriction that you request.
• You have the right to inspect and copy your health information as long as we maintain your health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must complete the Request to Inspect Medical Records Form. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant your request that the denial be reviewed.
• You have the right to request that we amend your health information that is incorrect or incomplete. To request an amendment, you must complete the Request to Amend Medical Records Form. We are not required to change your health information and we will provide you with information about procedure for addressing any disagreement with the denial.
• You have the right to receive an accounting of disclosures of your health information we have made after April 14,2003, for most purpose other than treatments, payment, health care operation, information provided to you, and certain government functions. To request an accounting, you must complete Request for Accounting of Disclosures Form. You must specify the time period by may not be longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
• You may request communication of your health information by alternative means or at alternative location. For example, you may request that health information; you must complete the Request for Alternative Communication Form. Your request must state how or when you would like to be contracted. We will accommodate all reasonable requests.

If you wish to exercise one or more of these rights, please contact this office at the above address or phone number.

Changes to this Notice of Privacy Practices
We reserve the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new notice effective for all medical information we maintain. Until such amendment is made, we are required by law to comply with the notice. The revised notice will be posted in this office and a paper copy will be available upon request.

For More Information or to Report a Problem
If you have any questions or would like additional information about our privacy practices, you may contact us at the above address or phone number. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation, with our form or with the Secretary of Health and Human Services.