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.
Contact Person:
Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Molly Harrison
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. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail 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.
Notice Revised and Effective: September 23, 2013.
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Carmel Eyecare LLC’s., Notice of Privacy Practices.
Copies of our Privacy Policy are available at any time from the Carmel Eyecare reception desk or in the Patient Center at www.carmeleyecare.com.
I hereby authorize any or all medical information to be disclosed to the following:
This includes anyone authorized to pick up glasses or contact lenses on your behalf.
This field is for validation purposes and should be left unchanged.