Effective Date: 4/07/03

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

This notice describes how our practice will use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are described in this notice. We are committed to the protection of medical information in accordance with the applicable law. A record of care and services you receive at our practice is needed to provide you with the quality care and comply with the legal requirements. The law requires us to make sure that your medical information is kept private. The law also requires us to provide a copy of this notice to you which explains our legal duties and privacy practices with respect to your medical information and follow the terms of this notice currently in effect.

This notice also describes your rights to access and control medical information. This information about you includes demographic information, that may identify you and relates to your past, present or future physical or mental health. Our medical information will include medical history or symptoms, examinations, test results, diagnosis and treatment plan.

If you have any questions in regards to this notice, please contact our privacy contact, Mary Jo Field, at 773-4444.

Uses and Disclosures of Health Information

In certain circumstances we will use or disclose your medical information for a number of different purposes. Each of these purposes is listed below:

Treatment: We may use or disclose your PHI to provide, coordinate, or manage your medical treatment or related services. Some examples of these services could include another physician, nursing home or extended care facility or another health care provider such as a laboratory, pharmacy or diagnostic testing center.

Payment: We may use or disclose your PHI to obtain payment for treatment or care that were provided at our practice. This could be your health insurance plan or third party payor in need for approval for planned treatment.

Health Care Operations: Practice will disclose medical information about you for daily business activities. These activities include, but not limited to, reviewing our treatment of you, training of medical and ophthalmic technical students and support staff. We may use or disclose your medical information to provide you with information about treatment alternatives or health related benefits and services that may be of interest to you, information to a member of your family, relative or a close friend that is directly involved in your healthcare. If you are unable to agree or object, we may disclose such information that is in your best interest based on our professional judgment. We may use or disclose information to notify or assist in notifying a family member of any other person that is responsible for your care.

Appointment Reminders: We may use and disclose PHI to contact you to remind you of an appointment. We may contact you by telephone or mail either at your home or office. We may, at your request, leave messages for you on an answering machine or voicemail. If you want to request that we communicate to you in a certain way or at a certain location, please contact our privacy contact, Mary JO Field, at 773-4444.

Others Involved in Your Healthcare: We may also disclose your PHI to a family member, other relative, close friend or any other person identified by you, such as an interpreter, that is involved in your care or payment related to your care. If you are unable to agree or object, we may disclose such information that is in your best interest based on our professional judgment.

Required By the Law: We may use or disclose your health information when federal, state, or local law requires disclosure. You will be notified of any such disclosures.

Public Health: We may disclose your health information for a public health activities and purposes to a public health official that is permitted by law to collect or receive information. The purpose of this disclosure is for controlling disease, injury or disability.

Communicable Disease: We may disclose your health information, if authorized by the law, to a person who may have been exposed to a common communicable disease or may otherwise be at risk of contracting or spreading the disease.

Health Oversight: We may disclose your health information to health oversight agency for activities authorized by the law, such as audits-or investigations, inspections and Licenser. This type of activity is necessary for government agencies to oversee the health care system government and benefit programs, other government regulatory programs and civil rights laws.

Legal Proceedings and Law Enforcement: We may disclose your health information for judicial or administrative proceedings when required by a court order or administrative tribunal. For law or enforcement purposes applicable legal requirements must be met: in response to a court order, subpoena, or summons; to identify or locate a suspect, fugitive, material witness or missing person; pertaining to a victim of a crime; suspicion of a death as a result of criminal conduct; in the event that a crime occurs on the premises of the practice and medical emergency (not on the practice's premises) and it is likely that a crime has occurred.

Coroners and Funeral Directors: We may disclose health information to a coroner or medical examination for identification purposes for the cause of death or as authorized by law. To the funeral directors as necessary to carry out their duties.

Research: We may disclose health information to researchers when an institutional review board has reviewed the research proposal and established protocols to ensure the privacy of your private health information.

Inmates: We may disclose your health information if you are an inmate in a correctional facility and our practice created or received your health information in the course of providing your care.

Criminal Activity: We may disclose your health information, as consistent with federal and state laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to health or safety of a person or public health. Private health information may also be disclosed in the event of law enforcement authorities to identify or apprehend an individual.

Organ and Tissue Donation: If you are an organ donor or recipient, we may release your health information to organizations that handle organ procurement or organ, eye or tissue transplantation to an organ bank, as necessary to facilitate organ tissue donation and transplantation.

Military and National Security: As a member of the armed forces, we may use or disclose your health information as required by the military command authorities, for the purpose of determining by the Department of Veterans Affairs of your eligibility of benefits or for foreign military personnel to appropriate foreign military authority. We may also disclose your health information to authorized federal officials for conducting national security and intelligence services.

Required Uses and Disclosures: By law, the practice must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et.seq.

Rights With Respect To Your Health Information

Right to Inspect and Copy: You have a right to inspect and copy your health information that has originated at the practice. We may charge you a reasonable fee for copying and mailing records. You must make a written request to our Medical Record Department. The practice has 30 days to satisfy your request.

Right to Request Restrictions: Have the right to as the practice not to use or disclose information for the purpose of treatment, payment or healthcare operations. You may also request that your health information not be disclosed to family members or friends who may be involved in your care as described in this Notice of Privacy Practices. This request must be made in writing with the specific restriction requested and to whom you want the restriction to apply.

Right to Amend: If you feel that your health information is incorrect or incomplete, you may request to amend the information. If you wish to request an amendment to your health information, contact our Privacy Contact, in writing, to request our form Request to Amend Health Information. In some cases, the practice may deny your request. If we deny your request, you have a right to file a statement of disagreement with us.

Right to a List of Disclosures: You have a right to receive a list of disclosures we have made of your PHI. Certain types of disclosures are not included in that list, such as disclosures to you or your legal representative, disclosures to carry out treatment, payment and healthcare operations. To request a disclosure list, submit your request, in writing, to our privacy contact. Your request must indicate a time period for the disclosures. We will notify you in writing of the cost involved in preparing this list.

Right to Request Alternative Means of Communications: You have the right to request that we communicate with you in a certain way or location. If you wish to make a request for an alternative method of communication, you must do so in writing to our privacy contact. Your request must state how or where you can be contacted. We will accommodate all reasonable requests.

Other Uses or Disclosures: Uses or disclosures of PHI not covered by this Notice of Privacy Practices will be made only with your written authorization. If you authorize us to use or disclose your PHI, you may revoke that authorization at anytime. However, in any case the practice will be able to use or disclose the health information to the extent practice has taken action in reliance on the authorization.

Right to Complain: If you believe your privacy rights have been violated, you may complain to our Privacy contact, Mary JO Field, or contact the United States Department of Health and Human Services: Office for Civil Rights, Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL. 60601, Phone: 312-886-2359, Fax: 312-886-1807.

Important Note Regarding this Notice of Privacy Practices

We reserve the right to revise or change this Notice of Privacy Practices. We reserve the right to make the new notice's provisions effective for all PHI that we maintain, including that created or received by us prior to the effective date of the new notice. The effective date is set forth on the first page. A copy of the current notice will also be posted on our website at www.kraffeye.com. In addition, each time you visit our practice, a copy of the current notice will be made available. If, after reading this notice, you have any questions, please contact our privacy contact, Mary JO Field, at: 773-777-4444.

Kraff Eye Institute
25 East Washington St., Suite 606, Chicago, IL 60602 | Tel: 312-338-1234
3115 N. Harlem Ave., Suite 300, Chicago, IL 60634 | Tel: 773-777-4444
E-mail: info@kraffeye.com Web: http://www.kraffeye.com

Your Lasik Chicago Specialist




	Notice of Privacy Practices Effective Date: 4/07/03 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This notice describes how our practice will use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are described in this notice. We are committed to the protection of medical information in accordance with the applicable law. A record of care and services you receive at our practice is needed to provide you with the quality care and comply with the legal requirements. The law requires us to make sure that your medical information is kept private. The law also requires us to provide a copy of this notice to you which explains our legal duties and privacy practices with respect to your medical information and follow the terms of this notice currently in effect. This notice also describes your rights to access and control medical information. This information about you includes demographic information, that may identify you and relates to your past, present or future physical or mental health. Our medical information will include medical history or symptoms, examinations, test results, diagnosis and treatment plan. If you have any questions in regards to this notice, please contact our privacy contact, Mary Jo Field, at 773-4444. Uses and Disclosures of Health Information In certain circumstances we will use or disclose your medical information for a number of different purposes. Each of these purposes is listed below: Treatment: We may use or disclose your PHI to provide, coordinate, or manage your medical treatment or related services. Some examples of these services could include another physician, nursing home or extended care facility or another health care provider such as a laboratory, pharmacy or diagnostic testing center. Payment: We may use or disclose your PHI to obtain payment for treatment or care that were provided at our practice. This could be your health insurance plan or third party payor in need for approval for planned treatment. Health Care Operations: Practice will disclose medical information about you for daily business activities. These activities include, but not limited to, reviewing our treatment of you, training of medical and ophthalmic technical students and support staff. We may use or disclose your medical information to provide you with information about treatment alternatives or health related benefits and services that may be of interest to you, information to a member of your family, relative or a close friend that is directly involved in your healthcare. If you are unable to agree or object, we may disclose such information that is in your best interest based on our professional judgment. We may use or disclose information to notify or assist in notifying a family member of any other person that is responsible for your care. Appointment Reminders: We may use and disclose PHI to contact you to remind you of an appointment. We may contact you by telephone or mail either at your home or office. We may, at your request, leave messages for you on an answering machine or voicemail. If you want to request that we communicate to you in a certain way or at a certain location, please contact our privacy contact, Mary JO Field, at 773-4444. Others Involved in Your Healthcare: We may also disclose your PHI to a family member, other relative, close friend or any other person identified by you, such as an interpreter, that is involved in your care or payment related to your care. If you are unable to agree or object, we may disclose such information that is in your best interest based on our professional judgment. Required By the Law: We may use or disclose your health information when federal, state, or local law requires disclosure. You will be notified of any such disclosures. Public Health: We may disclose your health information for a public health activities and purposes to a public health official that is permitted by law to collect or receive information. The purpose of this disclosure is for controlling disease, injury or disability. Communicable Disease: We may disclose your health information, if authorized by the law, to a person who may have been exposed to a common communicable disease or may otherwise be at risk of contracting or spreading the disease. Health Oversight: We may disclose your health information to health oversight agency for activities authorized by the law, such as audits-or investigations, inspections and Licenser. This type of activity is necessary for government agencies to oversee the health care system government and benefit programs, other government regulatory programs and civil rights laws. Legal Proceedings and Law Enforcement: We may disclose your health information for judicial or administrative proceedings when required by a court order or administrative tribunal. For law or enforcement purposes applicable legal requirements must be met: in response to a court order, subpoena, or summons; to identify or locate a suspect, fugitive, material witness or missing person; pertaining to a victim of a crime; suspicion of a death as a result of criminal conduct; in the event that a crime occurs on the premises of the practice and medical emergency (not on the practice's premises) and it is likely that a crime has occurred. Coroners and Funeral Directors: We may disclose health information to a coroner or medical examination for identification purposes for the cause of death or as authorized by law. To the funeral directors as necessary to carry out their duties. Research: We may disclose health information to researchers when an institutional review board has reviewed the research proposal and established protocols to ensure the privacy of your private health information. Inmates: We may disclose your health information if you are an inmate in a correctional facility and our practice created or received your health information in the course of providing your care. Criminal Activity: We may disclose your health information, as consistent with federal and state laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to health or safety of a person or public health. Private health information may also be disclosed in the event of law enforcement authorities to identify or apprehend an individual. Organ and Tissue Donation: If you are an organ donor or recipient, we may release your health information to organizations that handle organ procurement or organ, eye or tissue transplantation to an organ bank, as necessary to facilitate organ tissue donation and transplantation. Military and National Security: As a member of the armed forces, we may use or disclose your health information as required by the military command authorities, for the purpose of determining by the Department of Veterans Affairs of your eligibility of benefits or for foreign military personnel to appropriate foreign military authority. We may also disclose your health information to authorized federal officials for conducting national security and intelligence services. Required Uses and Disclosures: By law, the practice must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et.seq. Rights With Respect To Your Health Information Right to Inspect and Copy: You have a right to inspect and copy your health information that has originated at the practice. We may charge you a reasonable fee for copying and mailing records. You must make a written request to our Medical Record Department. The practice has 30 days to satisfy your request. Right to Request Restrictions: Have the right to as the practice not to use or disclose information for the purpose of treatment, payment or healthcare operations. You may also request that your health information not be disclosed to family members or friends who may be involved in your care as described in this Notice of Privacy Practices. This request must be made in writing with the specific restriction requested and to whom you want the restriction to apply. Right to Amend: If you feel that your health information is incorrect or incomplete, you may request to amend the information. If you wish to request an amendment to your health information, contact our Privacy Contact, in writing, to request our form Request to Amend Health Information. In some cases, the practice may deny your request. If we deny your request, you have a right to file a statement of disagreement with us. Right to a List of Disclosures: You have a right to receive a list of disclosures we have made of your PHI. Certain types of disclosures are not included in that list, such as disclosures to you or your legal representative, disclosures to carry out treatment, payment and healthcare operations. To request a disclosure list, submit your request, in writing, to our privacy contact. Your request must indicate a time period for the disclosures. We will notify you in writing of the cost involved in preparing this list. Right to Request Alternative Means of Communications: You have the right to request that we communicate with you in a certain way or location. If you wish to make a request for an alternative method of communication, you must do so in writing to our privacy contact. Your request must state how or where you can be contacted. We will accommodate all reasonable requests. Other Uses or Disclosures: Uses or disclosures of PHI not covered by this Notice of Privacy Practices will be made only with your written authorization. If you authorize us to use or disclose your PHI, you may revoke that authorization at anytime. However, in any case the practice will be able to use or disclose the health information to the extent practice has taken action in reliance on the authorization. Right to Complain: If you believe your privacy rights have been violated, you may complain to our Privacy contact, Mary JO Field, or contact the United States Department of Health and Human Services: Office for Civil Rights, Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL. 60601, Phone: 312-886-2359, Fax: 312-886-1807. Important Note Regarding this Notice of Privacy Practices We reserve the right to revise or change this Notice of Privacy Practices. We reserve the right to make the new notice's provisions effective for all PHI that we maintain, including that created or received by us prior to the effective date of the new notice. The effective date is set forth on the first page. A copy of the current notice will also be posted on our website at www.kraffeye.com. In addition, each time you visit our practice, a copy of the current notice will be made available. If, after reading this notice, you have any questions, please contact our privacy contact, Mary JO Field, at: 773-777-4444. Kraff Eye Institute 25 East Washington St., Suite 606, Chicago, IL 60602 \| Tel: 312-338-1234 3115 N. Harlem Ave., Suite 300, Chicago, IL 60634 \| Tel: 773-777-4444 E-mail: info@kraffeye.com Web: http://www.kraffeye.com Copyright © 2002 Kraff Eye Institute. All Rights Reserved. *Your Lasik Chicago Specialist*