Effective date of notice:12/20/2019

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you
notice of our privacy practices. This notice describes how we protect your health information and what rights you have
regarding it.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our
responsibilities to help you.
Get 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.
Ask us to correct your medical record. You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within
60 days.
Request confidential communications. You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
Ask us to limit what we use or share. 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 your request, and we may say “no” if it would affect your
care. 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.
Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared
your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the
disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as
any you asked us to make).
Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to
receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal
guardian, that person can exercise your rights and make choices about your health information.
File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by
contacting us at the number listed above. You can file a complaint with 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 www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a
complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for
how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will
follow your instructions. In these cases, you have both the right and choice to tell us to: 1) Share information with your
family, close friends, or others involved in your care. 2) Share information in a disaster relief situation. 3) Include your
information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and 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.
12/20/2019 Burke Optometry Attn: Germaine Burke, OD 441 S. Ham Lane, Ste B, Lodi, CA 95242 T 209.224.5454 F 209.224.8791 email schedule@burkeoptometry.com
In these cases we never share your information unless you give us written permission: 1) Marketing purposes. 2) Sale of
your information. 3) Fundraising – We may contact you for fundraising efforts, but you can tell us not to contact you
again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information?
We typically use or share your health information in the following ways. 1) Treat you. We can use your health
information and share it with other professionals who are treating you. 2) Run our organization. We can use and share
your health information to run our practice, improve your care, and contact you when necessary. 3) Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public
good, such as public health and research. We have to meet many conditions in the law before we can share your
information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues. We can share health information about you for certain situations such as: 1)
Preventing disease. 2) Helping with product recalls. 3) Reporting adverse reactions to medications. 4) Reporting suspected
abuse, neglect, or domestic violence. 5) Preventing or reducing a serious threat to anyone’s health or safety.
Do research. We can use or share your information for health research.
Comply with the law. We will share information about you if state or federal laws require it, including with the
Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement
organizations.
Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner,
or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. We can use or share health
information about you: 1) For workers’ compensation claims. 2) For law enforcement purposes or with a law enforcement
official. 3) With health oversight agencies for activities authorized by law. 4) For special government functions such as
military, national security, and presidential protective services.
Respond to lawsuits and legal actions. We can share health information about you in response to a court or
administrative order, or in response to a subpoena.

OUR RESPONSIBILITIES

1) We are required by law to maintain the privacy and security of your protected health information. 2) We will let you
know promptly if a breach occurs that may have compromised the privacy or security of your information. 3) We must
follow the duties and privacy practices described in this notice and give you a copy of it. 4) We will not use or share your
information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your
mind at any time. Let us know in writing if you change your mind. 5) For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. 6) Changes to the Terms of this Notice.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice
will be available upon request, in our office.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may
also call or write to notify you of other treatments or services available at our office that might help you.
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right
to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your
health information that we already have as well as to such information that we may generate in the future. If we change
our Notice of Privacy Practices, we will post the new one in our office and have copies available in our office.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or
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 at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone
number shown at the beginning of this Notice.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Notice of Privacy Practices.

Patient name______________________________________________________

Signature______________________________________Date_______________

OUR NOTICE OF PRIVACY PRACTICES

Burke Optometry Attn: Germaine Burke O.D.