Dr. Deborah Goldman & Associates
We Look Forward to Helping you see clearly

HIPPA Rules

Should you have any questions regarding the HIPAA Laws, please contact our Privacy Officer
Danny Fineman
danny@drgoldmanod.com


Wellington Office (Palm Beach County, Florida)
2205 State Road 7, ste. 400, Wellington, FL 33414
(561) 792-3387 - Phone
(561) 792-8055 - Fax 

Click on the link below to review the HIPAA Laws (Available in English and Spanish)
HIPAA Laws (Wellington, FL)

Dr. Deborah Goldman & Associates  2205 State Road 7, ste. 400, Wellington, FL 33414 Phone: 561-792-3387 Fax: 561-792-8055 dgoldman@od.foreyes.com

I. PRIVACY PRACTICE NOTICE | PLEASE REVIEW THIS NOTICE CAREFULLY.

This notice describes how we may use and disclose your health information and how you can get access to your information.

  • We take the privacy of our patients’ vision, health, financial and identity information very seriously. We understand your information is personal to

    you and we are committed to protecting this information on your behalf. Toward that end, we will not sell your vision health or personal information

    to a third party for any reason.

  • We have an organized health care arrangement with For Eyes Optical. We are independent optometrists who work next to or share space with For

Eyes. Everyone connected to this practice and For Eyes is committed to safeguarding your personal information from unauthorized use and disclosure.

Our Legal Duty
We are required by law to protect the privacy of your health information. We are required to give you this notice, which explains how we may use

information about you and when we can give out or "disclose" that information to others. This notice describes your rights regarding your health information. We are required by law to abide by the terms of this notice. This notice is effective September 23, 2013 and remains in effect until we replace it.

We must use and disclose your health information to provide that information to you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and to the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose your health information for your treatment, to pay for your services and to operate our business. For example, we may use or disclose your vision health information:

  • For Payment due us. Examples of how we use or disclose your health information for payment 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).

  • For Treatment, the coordination of your care or recall information. Examples of how we use or disclose information for treatment 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; getting copies of your health information from another professional that you may have seen before us; or sending health information to another professional that you may see after us.

  • For Health Care Operations as necessary to operate and manage our business activities related to providing and managing your vision and health care coverage. Examples of how we use or disclose 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.

  • To Provide You Information on Health Related Programs or Products such as alternative vision treatments and programs or about vision and health- related products and services, subject to limits imposed by law.

  • To Plan Sponsors. When coverage is through an employer sponsored group health plan, we may share summary health information, enrollment, and disenrollment information with the plan sponsor.

  • For Reminders. We may use or disclose vision and health information to send you reminders about your care, such as appointment reminders with your optometrist who provides your eye examination.

    We may use or disclose your health information in some limited circumstances without your permission. Not all of these situations will apply to us; some may never come up at all. Such uses or disclosures are:

  • As Required by Law. We may disclose information when required to do so by law.

  • To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your

    care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you

    are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.

  • For Public Health Activities such as reporting or preventing disease outbreaks.

  • For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information,

    including a social service or protective service agency.

  • For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and

    abuse investigations.

  • For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.

  • We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will post the revised notice in our office and give you a copy of the revised notice upon request. We will post the revised notice on our website at www.drgoldmanod.com. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.

  • You may request a copy of our Notice at any time. We will give you a copy at your first visit. It is posted at our registration desk and on our website at www.drgoldmanod.com

    How We Use or Disclose Information

For Eyes Optical Company. Notice of Privacy Practices. HIPAA 2013. Effective September 23, 2013 Page 1

  • For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.

  • To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster.

  • For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.

  • For Workers' Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.

  • For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.

  • To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.

  • To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

  • To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

  • To Opticians with Organized Health Care Arrangements that perform optician services in space next to or shared with our practice if the information is necessary to conduct treatment, payment or healthcare operation functions. We require opticians to protect the privacy of your information.

  • For Data Breach Notification Purposes. We may use your contact information to provide legally required notices of unauthorized acquisition, access,

    or disclosure of your health information. We may send notice directly to you or provide notice to the sponsor of your plan through which you receive

    coverage.

  • Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy protections that restrict the use and

    disclosure of certain health information, including highly confidential information about you. "Highly confidential information" may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information: HIV/AIDS; Mental health; Genetic tests; Alcohol and drug abuse; Sexually transmitted diseases and reproductive health information; and Child or adult abuse or neglect, including sexual assault.

    • If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is

      our intent to meet the requirements of the more stringent law.

    • Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a

      written authorization from you. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writing, except if we have already acted based on your authorization.

      What Are Your Rights with Respect to Your Health Information:

  • You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You have the right to

    ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction unless you pay cash for the services rendered.

  • You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address). We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing. Mail your request to For Eyes.

  • You have the right to see and obtain a copy of health information that may be used to make decisions about you such as claims and case or medical management records. You may receive a copy of your health information. You must make a written request to inspect and copy your health information. If you request a summary of this information, we will provide you with one for a fee. We may charge a reasonable fee for any copies. If we deny your request, you have the right to have the denial reviewed. If we maintain an electronic health record containing your health information, you have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify. We may charge a reasonable fee for sending the electronic copy of your health information.

  • You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. If we deny your request, you may have a statement of your disagreement added to your health information.

  • You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.

    Exercising Your Rights

  • Contact Us. If you have any questions about this notice or want to exercise any of your rights, please call.

  • Submit a Written Request. Mail your written requests for modifying or cancelling a confidential communication, for copies of your records, or for

    amendments to your record, at the following address, making sure that you provide your name, address, phone, and/or fax and email address: For Eyes Optical Company. Notice of Privacy Practices. HIPAA 2013. Effective September 23, 2013 Page 2

page2image57152

You have the right to a copy of this notice. You may ask for a copy of this notice at any time. You may obtain a copy of this notice on our website at www.drgoldmanod.com or by request via mail or email or asking us for a copy.

page2image59784

Privacy Officer
Danny Fineman

2205 State Road 7, ste. 400, Wellington, FL 33414 Phone: 561-792-3387 Fax: 561-792-8055 dgoldman@od.foreyes.com

  • File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us.

  • You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you

    for filing a complaint. Contact: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

    II. FINANCIAL INFORMATION PRIVACY NOTICE | PLEASE REVIEW IT CAREFULLY.

    This part of the notice describes how we may use and disclose your financial information and how you can get access to this information.

    We are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, "personal financial information" means information about a patient or customer that identifies the individual, is not generally publicly available, and is collected from the individual or is obtained in connection with providing vision services and/or health care coverage to the individual.

    Information We Collect

  • We collect personal financial information about you from the following sources:

  • Information we receive from you on applications or other forms, such as name, address, age, medical information and Social Security number;

  • Information about your transactions with us, our affiliates or others, such as premium payment, claims history and payment card information; and

  • Information from consumer reports.

    Disclosure of Information

    We do not disclose personal financial information about you to any third party, except as required or permitted by law. For example, in the course of our general business practices, we may, as permitted by law, disclose any of the personal financial information that we collect about you, without your authorization, to the following types of institutions:

  • To our corporate affiliates, which include financial service providers, such as other insurers, and non-financial companies, such as data processors;

  • To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain your account(s), or respond to court orders and legal investigations; and

  • To nonaffiliated companies that perform services for us, including sending promotional communications on our behalf.

    Confidentiality and Security

    We maintain physical, electronic and procedural safeguards in compliance with state and federal standards to guard your personal financial information. These measures include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information.

    Questions About this Notice

    If you have any questions about this notice, please call us at the number listed under the Privacy Officer or the beginning of this notice.

For Eyes Optical Company. Notice of Privacy Practices. HIPAA 2013. Effective September 23, 2013 Page 3

Summary of Federal Laws

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Alcohol & Drug Abuse Information

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We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

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Genetic Information

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We are not allowed to use genetic information for underwriting purposes.

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Summary of State Laws where For Eyes conducts Business

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General Health Information

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.
We will not use and/or disclosure information regarding certain public assistance programs except for certain purposes.

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2)

to specific recipients.

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain

limited circumstances and/or (2) to specific recipients.

Alcohol and Drug Abuse

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or

disclose only (2) to specific recipients.

Genetic Information

We are not allowed to disclose genetic information without your written consent.

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.

Mental Health

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.

States

CA, PR NJ

IN

CA, FL, IN, NJ, PR

GA, IL, IN, NH

CA, IL FL, GA,

MA, MD, NJ, NH FL, GA, MD, VA

CA, FL, GA, IL, IN, NH, PA, PR FL

CA, DC, IL, IN, MA, PR

IL, NJ

For Eyes Optical Company. Notice of Privacy Practices. HIPAA 2013. Effective September 23, 2013

Page 4

How To File a Complaint Contact:

If you believe that we violated your (or someone else’s) health information privacy rights or committed another violation of the Privacy or Security Rule, you may file a complaint with this practice or with the Office of Civil Rights (OCR).

Dr. Deborah Goldman & Associates
Privacy Officer
Danny Fineman

2205 State Road 7, ste. 400, Wellington, FL 33414 Phone: 561-792-3387 Fax: 561-792-8055 

Email: Danny@drgoldmanod.com

Office of Civil Rights Regional Offices Where For Eyes Operates (http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html)

page5image5328

Region I - Boston (Massachusetts, New Hampshire)

Office for Civil Rights
U.S. Department of Health and Human Services Government Center
J.F. Kennedy Federal Building - Room 1875 Boston, MA 02203
Voice phone (800) 368-1019
FAX (617) 565-3809
TDD (800) 537-7697

Region II - New York (New Jersey, Puerto Rico)

Office for Civil Rights
U.S. Department of Health and Human Services Jacob Javits Federal Building
26 Federal Plaza - Suite 3312
New York, NY 10278
Voice Phone (800) 368-1019
FAX (212) 264-3039
TDD (800) 537-7697

Region III - Philadelphia (District of Columbia, Pennsylvania, Virginia)

Office for Civil Rights
U.S. Department of Health and Human Services 150 S. Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
Main Line (800) 368-1019
FAX (215) 861-4431
TDD (800) 537-7697

Region IV - Atlanta (Florida, Georgia)

Office for Civil Rights
U.S. Department of Health and Human Services Sam Nunn Atlanta Federal Center, Suite 16T70 61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Voice Phone (800) 368-1019
FAX (404) 562-7881
TDD (800) 537-7697

Region V - Chicago (Illinois, Indiana)

Office for Civil Rights
U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone (800) 368-1019
FAX (312) 886-1807
TDD (800) 537-7697

Region IX - San Francisco (California)

Office for Civil Rights
U.S. Department of Health and Human Services 90 7th Street, Suite 4-100
San Francisco, CA 94103
Voice Phone (800) 368-1019
FAX (415) 437-8329
TDD (800) 537-7697

For Eyes Optical Company. Notice of Privacy Practices. HIPAA 2013. Effective September 23, 2013

Page 5 


HIPAA Laws (Wellington, FL) Spanish Language

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    nuestro&escritorio&de&registro&de&pacientes&y&en&nuestras&tiendas.& &

    Cómo$utilizamos$o$divulgamos$la$información&

  • Para$actividades$de$supervisión$de$salud$a&una&agencia&de&supervisión&de&salud,&para&las&actividades&autorizadas&por&la&ley,&tales&como&una& acreditación,&auditorías&gubernamentales&e&investigaciones&de&fraude&y&abuso.&

  • Para$procesos$judiciales$o$administrativos,$por&ejemplo,&en&respuesta&a&una&orden&judicial,&orden&de&allanamiento&o&citación.&

  • Para$propósitos$de$cumplimiento$de$la$ley.&Podemos&divulgar&su&información&médica&a&un&agente&del&orden&público&para&propósitos&tales&como&

    proporcionar&información&limitada&para&localizar&a&una&persona&desaparecida&o&reportar&un&crimen.&

  • Para$evitar$una$amenaza$grave$contra$la$salud$o$seguridad$suya,&de&otra&persona&o&del&público,&al,&por&ejemplo,&divulgar&información&a&las&agencias&de&

    salud&pública&o&autoridades&del&orden&público&o&en&caso&de&una&emergencia&o&desastre&natural.&

  • Para$las$funciones$gubernamentales$especializadas$tales&como&actividades&militares&y&de&veteranos,&actividades&de&seguridad&nacional&y&de&

    inteligencia&y&servicios&de&protección&para&el&Presidente&y&otros.&

  • Para$la$compensación$de$trabajadores$lesionados$según&lo&autorizan,&o&hasta&donde&sea&necesario&cumplir&con,&las&leyes&estatales&de&compensación&

    de&trabajadores&que&regulan&las&lesiones&o&enfermedades&relacionadas&con&el&trabajo.&

  • Para$los$propósitos$de$investigación$tales&como&investigación&relacionada&con&la&evaluación&de&ciertos&tratamientos&o&la&prevención&de&enfermedades&

    o&discapacidades,&si&el&estudio&de&investigación&cumple&con&los&requisitos&de&la&ley&de&privacidad.&&

  • Para$proporcionar$información$sobre$los$difuntos.$Podemos&divulgar&información&a&un&forense&o&médico&forense&para&identificar&a&una&persona&

    difunta,&determinar&la&causa&de&muerte&o&según&lo&autorice&la&ley.&También&podemos&divulgar&información&a&los&directores&de&funeraria&según&sea&

    necesario&para&que&realicen&sus&tareas.&

  • Para$las$instituciones$penitenciarias$o$agentes$del$orden$público$si&usted&es&recluso&de&una&institución&penitenciaria&o&está&bajo&la&custodia&de&un&

    agente&del&orden&público,&pero&solo&si&es&necesario&(1)&para&que&la&institución&le&proporcione&atención&médica;&(2)&para&proteger&su&salud&y&seguridad&o&

    la&salud&y&seguridad&de&otros;&o&(3)&para&la&protección&y&seguridad&de&la&institución&penitenciaria.&

  • Para$los$asociados$comerciales&que&realizan&funciones&en&nuestro&nombre&o&que&nos&proporcionan&servicios&si&la&información&es&necesaria&para&tales&

    funciones&o&servicios.&Se&requiere&que&nuestros&asociados&comerciales,&bajo&contrato&con&nosotros,&protejan&la&privacidad&de&su&información&y&no&se&les&

    permite&utilizar&ni&divulgar&ninguna&información&que&no&sea&la&que&se&especifica&en&nuestro&contrato.&

  • Para$los$técnicos$de$optometrías&con&arreglos&para&la&atención&médica&organizada&que&realizan&servicios&de&optometría&dentro&de&For&Eyes&o&que&

    comparten&espacio&con&For&Eyes,&si&la&información&es&necesaria&para&realizar&las&funciones&del&tratamiento,&pago&u&operación&de&la&atención&médica.&

    Exigimos&que&los&técnicos&de&optometrías&protejan&la&privacidad&de&su&información.&

  • $Para$propósitos$de$notificación$de$violación$de$datos.&Podemos&utilizar&su&información&de&contacto&para&proporcionar&avisos&legalmente&requeridos&

    de&adquisición,&acceso&o&divulgación&no&autorizada&de&su&información&médica.&Podemos&enviarle&el&aviso&directamente&a&usted&o&proporcionar&un&aviso&

    al&patrocinador&de&su&plan&a&través&del&cual&recibe&la&cobertura.$

  • Restricciones$adicionales$sobre$el$uso$y$la$divulgación.$Ciertas&leyes&federales&y&estatales&pueden&requerir&protecciones&de&privacidad&especiales&que&

    restringen&el&uso&y&la&divulgación&de&cierta&información&médica,&incluso&la&información&altamente&confidencial&acerca&de&usted.&"La&información& altamente&confidencial"&puede&incluir&información&confidencial&bajo&las&leyes&federales&que&regulan&la&información&sobre&el&consumo&de&alcohol&y& drogas&e&información&genética&así&como&las&leyes&estatales&que&con&frecuencia&protegen&los&siguientes&tipos&de&información:&VIH/SIDA;&salud&mental;& pruebas&genéticas;&consumo&de&alcohol&y&drogas;&enfermedades&de&transmisión&sexual&e&información&sobre&la&salud&reproductiva;&y&abuso&o& negligencia&con&niños&o&adultos,&incluso&abuso&sexual.&

    • Si&el&uso&o&la&divulgación&de&información&médica&descrito&anteriormente&en&este&aviso&está&prohibido&o&limitado&materialmente&por&otras&leyes& que&aplican&a&nosotros,&es&nuestra&intención&satisfacer&los&requisitos&de&la&ley&más&estricta.&&$

    • Excepto&para&los&usos&y&las&divulgaciones&descritas&y&limitadas&como&se&establece&en&este&aviso,&utilizaremos&y&divulgaremos&su&información& médica&solo&con&su&autorización&por&escrito.&Una&vez&que&nos&brinde&la&autorización&para&publicar&su&información&médica,&no&podemos&garantizar& que&la&persona&a&quien&se&le&proporciona&la&información,&no&la&divulgará.&Puede&retirar&o&"revocar"&su&autorización&escrita&en&cualquier&momento& por&escrito,&excepto&si&ya&hemos&actuado&con&base&en&su&autorización.&$

      $ ¿Cuáles$son$sus$derechos$respecto$a$su$información$médica?:$

  • Tiene$derecho$a$pedir$que$se$restrinjan$los&usos&o&divulgaciones&de&su&información&para&el&tratamiento,&pago&u&operaciones&de&atención&médica.&Tiene&

    derecho&a&pedir&que&se&restrinjan&las&divulgaciones&a&los&familiares&u&otros&que&están&involucrados&en&su&atención&médica&o&pago&de&su&atención& médica.&También&podemos&tener&políticas&sobre&el&acceso&de&dependientes&que&autorizan&a&sus&dependientes&a&solicitar&ciertas&restricciones.&Tenga&en& cuenta&que&si&bien&intentamos&satisfacer&su&solicitud&y&permitir&que&las&solicitudes&sean&congruentes&con&nuestras&políticas,&no&se&nos&exige&aceptar& ninguna&restricción&a&menos&que&pague&en&efectivo&por&los&servicios&prestados.&

  • Tiene$derecho$a$pedir$recibir$comunicaciones$confidenciales$de&información&en&una&manera&distinta&o&en&un&lugar&diferente&(por&ejemplo,&al&enviar& información&a&un&apartado&postal&en&lugar&de&hacerlo&a&su&dirección&de&residencia).&Aceptaremos&las&solicitudes&verbales&para&recibir&comunicaciones& confidenciales,&pero&las&solicitudes&para&modificar&o&cancelar&una&solicitud&de&comunicación&confidencial&anterior&se&deben&hacer&por&escrito.&Envíe&su& solicitud&a&esta&oficina.&&

  • Tiene$derecho$a$ver$y$obtener$una$copia$de&la&información&médica&que&se&puede&utilizar&para&tomar&decisiones&sobre&usted,&tal&como&reclamos&y& registros&de&administración&médica&y&del&caso.&Puede&recibir&una&copia&de&su&información&médica.&Debe&hacer&una&solicitud&por&escrito&para& inspeccionar&y&copiar&su&información&médica.&Si&solicita&un&resumen&de&esta&información,&le&proporcionaremos&una&a&un&costo.&Podemos&cobrar&precio& razonable&por&cualquier&copia.&Si&rechazamos&su&solicitud,&tiene&derecho&a&que&le&revisen&la&denegación.&Si&mantenemos&un&registro&médico&electrónico& que&contenga&su&información&médica,&tiene&derecho&a&solicitar&que&le&enviemos&una&copia&de&su&información&médica&en&un&formato&electrónico&o&a&un& tercero&que&usted&identifique.&Podemos&cobrar&una&cuota&razonable&por&enviar&la&copia&electrónica&de&su&información&médica.&

  • Tiene$derecho$a$pedir$que$se$modifique$la&información&que&mantenemos&sobre&usted&si&considera&que&su&información&médica&está&equivocada&o& incompleta.&Su&solicitud&se&debe&presentar&por&escrito&y&proporcionar&los&motivos&para&la&enmienda&solicitada.&Si&rechazamos&su&solicitud,&se&puede& agregar&una&declaración&de&su&desacuerdo&a&su&información&médica.&&

  • Tiene$derecho$a$recibir$una$explicación$de&ciertas&divulgaciones&que&nosotros&hayamos&hecho&de&su&información&durante&los&seis&años&anteriores&a&su& solicitud.&Esta&explicación&no&incluirá&las&divulgaciones&de&información&hechas:&(i)&antes&del&14&de&abril&de&2003;&(ii)&para&propósitos&del&tratamiento,& pago&y&operaciones&de&atención&médica;&(iii)&a&usted&o&de&acuerdo&con&su&autorización;&y&(iv)&a&las&instituciones&penitenciarias&o&agentes&del&orden& público;&y&(v)&otras&divulgaciones&para&las&que&la&ley&federal&no&nos&requiere&proporcionar&una&explicación.&

page2image14856 page2image15016

Aviso&de&prácticas&de&privacidad.&Vigente&23&de&septiembre&de&2013& & & Página&2&de&3&

page3image384

Tiene$derecho$a$recibir$una$copia$de$este$aviso.& Puede& solicitar& una& copia& de& nuestro& aviso& en& cualquier& momento.& Puede& obtener& una& copia& solicitándola&&a&través&del&correo&electrónico&o&pedirnos&una&copia&directamente&a&nosotros.&

$ Cómo$ejercer$sus$derechos$

  • Comuníquese$con$el&Doctor&de&Optometría&toma.&Si&tiene&alguna&pregunta&sobre&este&aviso&o&desea&ejercer&cualquiera&de&sus&derechos,&llame&&

    por&teléfono.&&

  • Envíe$una$solicitud$por$escrito.&Envíe&por&correo&sus&solicitudes&por&escrito&para&modificar&o&cancelar&una&comunicación&confidencial,&para&obtener&

    copias&de&sus&registros&o&para&hacer&enmiendas&a&su&registro,&a&la&siguiente&dirección,&asegurándose&de&proporcionar&su&nombre,&dirección,&teléfono&o& fax&y&dirección&de&correo&electrónico:&

    Privacy&Officer& Danny&Fineman&

    2205&State&Rd&7,&Ste&400,&Wellington,&FL&33414& Phone:&561c792c3387&|&Fax:&561c792c8055&|&Email:&danny@drgoldmanod.com&

  • Presentar$una$queja.$Si&considera&que&sus&derechos&de&privacidad&han&sido&violados,&puede&presentar&una&queja&con&nosotros.&

  • También$puede$notificar$al$Secretario$del$Departamento$de$Salud$y$Servicios$Humanos$de$EE.$UU.$acerca&de&su&queja.$No&tomaremos&ninguna&acción&

    contra&usted&por&presentar&una&queja.&Contacto:&http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html& &&

    II.$$AVISO$DE$PRIVACIDAD$DE$LA$INFORMACIÓN$FINANCIERA$|$POR$FAVOR$REVÍSELO$CUIDADOSAMENTE.$

    Esta&parte&del&aviso&describe&cómo&podemos&usar&y&divulgar&su&información&financiera&y&cómo&puede&obtener&acceso&a&esta&información.&
    &&
    Estamos&comprometidos&con&mantener&la&confidencialidad&de&su&información&financiera&personal.&Para&los&propósitos&de&este&aviso,&la& "información&financiera&personal"&significa&la&información&sobre&un&paciente&o&cliente&que&identifica&a&la&persona,&no&está&generalmente& disponible&al&público,&y&se&obtiene&de&la&persona&o&en&conexión&con&proporcionar&cobertura&de&los&servicios&de&visión&o&de&atención&médica&a& la&persona.&

    && Información$que$recopilamos&

  • Recopilamos&información&financiera&personal&sobre&usted&de&las&siguientes&fuentes:&

  • La&información&que&recibimos&de&usted&en&las&solicitudes&u&otros&formularios,&tales&como&nombre,&dirección,&edad,&información&médica&y&número&de&

    Seguro&Social;&&

  • Información&sobre&sus&transacciones&con&nosotros,&nuestros&afiliados&u&otros,&tal&como&pago&de&prima,&historial&de&reclamos&e&información&de&tarjetas&

    de&pago;&y&

  • Información&de&los&reportes&del&consumidor.&
    &&
    Divulgación$de$información& No&divulgamos&la&información&personal&financiera&sobre&usted&a&terceros,&excepto&según&lo&requiera&o&permita&la&ley.&Por&ejemplo,&en&el& curso&de&nuestras&prácticas&de&negocios&generales,&podemos,&según&lo&permita&la&ley,&divulgar&cualquier&información&personal&financiera&que& recopilamos&de&usted,&sin&su&autorización,&a&los&siguientes&tipos&de&instituciones:&

  • Nuestros&afiliados&corporativos,&que&incluyen&los&proveedores&de&servicios&financieros,&tales&como&otras&aseguradoras&y&compañías&no&financieras,&

    tales&como&los&procesadores&de&datos;&&

  • Empresas&no&afiliadas,&para&nuestros&propósitos&negocios&diarios,&tal&como&procesar&sus&transacciones,&mantener&sus&cuentas&o&responder&a&las&

    órdenes&judiciales&e&investigaciones&legales;&y&&

  • Empresas&no&afiliadas&que&nos&prestan&servicios,&incluyendo&el&envío&de&comunicaciones&promocionales&por&nuestra&parte.&

    &
    Confidencialidad$y$seguridad& &Mantenemos&protecciones&físicas,&electrónicas&y&de&procedimiento&en&cumplimiento&con&los&estándares&estatales&y&federales&para&proteger& su&información&personal&financiera.&Estas&medidas&incluyen&protecciones&de&las&computadoras,&archivos&y&edificios&protegidos&y& restricciones&sobre&quién&puede&acceder&a&su&información&personal&financiera.&&
    &&
    Preguntas$sobre$este$aviso&
    Si&tiene&alguna&pregunta&sobre&este&aviso,&llame&a&
    El&Doctor&de&Optometría&teléfono&«Phone».&
    &

Aviso&de&prácticas&de&privacidad.&Vigente&23&de&septiembre&de&2013& & & Página&3&de&3


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