Notice of Privacy Practices Effective date
of notice: April 14, 2003.
Golden Gate Optometry 540 Davis Street, San Francisco, CA
94111 (415) 956 - 1850 Fax (415) 391-3852
This notice describes how medical information about you
may be used and disclosed, and how you can obtain access to this information.
Please review it carefully.
We respect our legal obligation to keep health information,
that identifies you, private. The law obligates us to give you notice
of our privacy practices. Generally, we can only use your health information
in our office or disclose it outside of our office, without your written
permission, for purposes of treatment, payment or healthcare operations.
In most other situations, we will not use or disclose your health information
unless you sign a written authorization form. In some limited situations,
the law allows or requires us to disclose your health information without
Uses or Disclosures of Health Information Examples
of how we use information for treatment purposes:
- When we set
up an appointment for you.
- When our technician or doctor tests
- When the doctor prescribes glasses or contact lenses.
- When the doctor prescribes medication.
- When our staff
helps you select and order glasses or contact lenses.
We may disclose your health information outside of our office
for treatment purposes, for example:
- If we refer you to another
doctor or clinic for eye care or low vision aids or services.
- If we send a prescription for glasses or contacts to another professional
to be filled.
- When we provide a prescription for medication to
- When we phone to let you know that your glasses
or contact lenses are ready to be picked up.
Sometimes we may ask for copies of your health information
from another professional that you may have seen before.
We may use your health information within our office or
disclose your health information outside of our office for payment purposes.
Some examples are:
- When our staff asks you about health or vision
care plans that you may belong to, or about other sources of payment for
- When we prepare bills to send to you or your health
or vision care plan.
- When we process payment by credit card and
when we try to collect unpaid amounts due.
- When bills or claims
for payment are mailed, faxed, or sent by computer to you or your health
or vision plan.
- When we occasionally have to ask a collection
agency or attorney to help us with unpaid amounts due.
We use and disclose your health information for healthcare
operations in a number of ways. Health care operations means those administrative
and managerial functions that we have to do in order to run our office.
We may use or disclose your health information, for example, for financial
or billing audits, for internal quality assurance, for personnel decisions,
to enable our doctors to participate in managed care plans, for the defense
of legal matters, to develop business plans, and for outside storage of
We may call to remind you of scheduled appointments.
Uses & Disclosures without an Authorization In some
limited situations, the law allows or requires us to use or disclose your
health information without your permission. Not all of these situations
will apply to us; some may never happen at our office at all. Such uses
or disclosures are:
- A state or federal law that mandates certain
health information be reported for a specific purpose.
health purposes, such as contagious disease reporting, investigation or
surveillance; and notices to and from the Food and Drug Administration
regarding drugs or medical devices.
- Disclosures to governmental
authorities about victims of suspected abuse, neglect or domestic violence.
- Uses and disclosures for health oversight activities, such as
for the licensing of doctors, audits by Medicare or Medicaid, or investigation
of possible violations of healthcare laws.
- Disclosures for judicial
and administrative proceedings, such as in response to subpoenas or orders
of courts or administrative agencies.
- Disclosures for law enforcement
purposes, such as to provide information about someone who is or is suspected
to be a victim of a crime; to provide information about a crime at our
office; or to report a crime that happened somewhere else.
to a medical examiner to identify a dead person or to determine the cause
of death; or to funeral directors to aid in burial; or to organizations
that handle organ or tissue donations.
- Uses or disclosures for
health related research.
- Uses and disclosures to prevent a serious
threat to health or safety.
- Uses or disclosures for specialized
government functions, such as for the protection of the president or high
ranking government officials; for lawful national intelligence activities;
for military purposes; or for the evaluation and health of members of
the foreign service.
- Disclosures relating to workers’ compensation
- Disclosures to business associates who perform healthcare
operations for us and who agree to keep your health information private.
Other Disclosures We will not make any other uses or disclosures
of your health information unless you sign a written authorization form.
You do not have to sign such a form. If you do sign one, you may revoke
it at any time unless we have already acted in reliance upon it.
Your Rights Regarding Your Health Information The law gives
you many rights regarding your health information.
- You can ask
us to restrict our uses and disclosures for purposes of treatment (except
emergency treatment), payment or healthcare operations. We do not have
to agree to do this, but if we agree, we must honor the restrictions that
you want. To ask for a restriction, send a written request to Lillian Shen
(Privacy Officer/Contact Person) at the address or fax shown at the beginning
of this notice.
- You can ask us to communicate with you in a confidential
way, such as by phoning you at work rather than at home or by mailing
health information to a different address. We will accommodate these requests
if they are reasonable, and if you pay us for any extra cost. If you want
to ask for confidential communications, send a written request to Lillian
Shen (Privacy Officer/Contact Person) at the address or fax shown at
the beginning of this notice.
- You can ask to see or to get photocopies
of your health information. By law, there are a few limited situations
in which we can refuse to permit access or copying. Primarily, however,
you will be able to review or have a copy of your health information within
30 days of asking us. You may have to pay for photocopies in advance.
If we deny your request, we will send you a written explanation, and instructions
about how to get an impartial review of our denial if one is legally required.
By law, we can have one 30-day extension of the time for us to give you
access or photocopies if we sent you a written notice of the extension.
If you want to review or get photocopies of your health information, send
a written request to Lillian Shen (Privacy Officer/Contact Person)at
the address or fax shown at the beginning of this notice.
can ask us to amend your health information if you think that it is incorrect
or incomplete. If we agree, we will amend the information within 60 days
from when you ask us. We will send the corrected information to persons
who we know got the wrong information, and others that you specify. If
we do not agree, you can write a statement of your position, and we will
include it with your health information along with any rebuttal statement
that we may write. Once your statement of position and/or rebuttal is
included in your health information, we will send it along whenever we
make a permitted disclosure of your health information. By law, we can
have one 30-day extension of time to consider a request for amendment
if we notify you in writing of the extension. If you want to ask us to
amend your health information, send a written request, including your
reasons for the amendment, to Lillian Shen (Privacy Officer/Contact Person)
at the address or fax shown at the beginning of this notice.
can get a list of the disclosures that we have made of your health information
within the past six years (or a shorter period if you want), except disclosures
for purposes of treatment, payment or health care operations, disclosures
made in accordance with an authorization signed by you, and some other
limited disclosures. You are entitled to one such list per year without
charge. If you want more frequent lists, you will have to pay for them
in advance. We will usually respond to your request within 60 days of
receiving it, but by law we can have one 30-day extension of time if we
notify you of the extension in writing. If you want a list, send a written
request to Lillian Shen (Privacy Officer/Contact Person) at the address
or fax shown at the beginning of this notice.
Our Notice of Privacy Practices 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 in compliance
with and 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 notice
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 to 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 Lillian Shen
(Privacy Officer/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 Lillian Shen (Privacy Officer/Contact
Person) at the address or phone number shown at the beginning of this
Golden Gateway Commons • 540 Davis
Street • San Francisco, CA 94111
Notice of Privacy