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EYE ASSOCIATES OF NORTHEAST LOUISIANA  SURGERY CENTER OF WEST MONROE
NOTICE OF PRIVACY PRACTICES
This is only a summary of our Notice of Privacy Practices. We encourage you to read the full Notice posted in our lobby.
If you would like a paper copy, please ask the receptionist.
HOW WE USE AND DISCLOSE YOUR INFORMATION
We will obtain your written authorization for any uses and disclosures of protected health information "PHI" not described
in the Notice of Privacy Practices.
Treatment, Payment, and Health Care Operations. We may use your PHI in order to provide your medical care; to bill for
our services and to collect payment from you or your insurance company; and for the general operation of our business.
Marketing, Fundraising, and Sale of PHI. We will obtain your prior written authorization before sending you certain marketing
communications. We may use or disclose your demographic information in order to contact you for our fundraising activities,
but you have the right to opt out of such communications. If you do not wish to be contacted, please contact our Privacy
Officer. We will not sell your health information or otherwise use or disclose your medical information for marketing purposes
without your prior written authorization.
We may use your PHI as otherwise authorized or required by law for such purposes as:
 public health reporting and oversight activities
 communicating with your family or caregivers
 judicial, administrative, or law enforcement proceedings
 sending appointment reminders
 complying with workers’ compensation laws
YOU HAVE THE RIGHT TO:
 Request certain restrictions on our use and disclosure of your PHI.
 Inspect and copy your medical record.
 Request communications from us by specific means or locations.
 Ask us to correct the information in your medical record.
 Receive an accounting of disclosures of your PHI by our practice.
 Be notified in the case of a breach of unsecured PHI.
CONTACT US
Contact our Privacy Officer with any questions, comments, or complaints or to exercise any of your rights:
Mary Sue Jacka, Administrator
1804 N 7th Street  West Monroe, LA 71291 | Ph: (318) 325-2610
By signing this form, you acknowledge that you have been informed that Eye Associates of Northeast Louisiana and Surgery
Center of West Monroe provide information about how we may use and disclose your protected health information.
Eye Associates of Northeast Louisiana and Surgery Center of West Monroe may use the following methods of communicaiton
regarding information related to my personal health, treatment or payment for treatment. I acknowledge I am responsible for
updating this information as necessary. This request supersedes any prior request for methods of communication I may
have made.
 Contact me by phone at home________________________
 Work___________________
 Cell___________________
 May leave a message on my voice mail/answering machine
 Email________________________________________
 May speak to anyone who answers the phone
 May only speak to_____________________________________________
 May leave a message for me at my work phone number.
Signature:_________________________________________________________________ Date:___________________
(Patient / Parent / Conservator / Guardian)
Practice Representative:_____________________________________________________

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