Patient Registration And History Form Family Eye Health Associate (Page 4 of 7) in pdf

Patient Registration And History Form Family Eye Health Associate Page 4

NOTICE OF PRIVACY PRACTICES

Family Eye Health Associates, LLC

John C. Sellechio, O.D. ~ Janice M.Gardner, O.D.

2374 Post Road, Suite 104, Warwick, RI 02886

Phone: (401) 921-0098

Fax: (401) 921-0073

Web:

Office Contact: Kim Johnson

Effective date of notice: January 1, 2015

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get

access to this information. Please review it carefully.

Your Rights. You have the right to:

 Get a copy of your paper or electronic medical record

 Correct your paper or electronic medical record

 Request confidential communication

 Ask us to limit the information we share

 Get a list of those with whom we’ve shared your information

 Get a copy of this privacy notice

 Choose someone to act for you

 File a complaint if you believe your privacy rights have been violated

Your Choices. You have some choices in the way that we use and share information as we:

 Tell family and friends about your condition

 Provide disaster relief

 Include you in a hospital directory

 Provide mental health care

 Market our services and sell your information

 Raise funds

Our Uses and Disclosures. We may use and share your information as we:

 Treat you

 Run our organization

 Bill for your services

 Help with public health and safety issues

 Do research

 Comply with the law

 Respond to organ and tissue donation requests

 Work with a medical examiner or funeral director

 Address workers’ compensation, law enforcement, and other government requests

Patient Registration And History Form Family Eye Health Associate Page 4