Notice of Privacy Practices

Effective Date: April 14, 2003

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.

If you have any questions about this notice, please contact Connie Ferrante.

WHO IS REQUIRED TO FOLLOW THE TERMS OF THS NOTICE.

This notice describes our medical group's privacy practices and that of:

• Any health care professional authorized to enter information into your medical record.

• All departments and units of the medical practice.

• All employees and staff of our medical practice.

This notice applies to: Brookhaven Eye Surgery E. Patchogue and S. Setauket locations. All of these sites and locations follow the terms of this notice. In addition, these locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to maintaining the confidentiality of medical information about you. We create a record of the care and services you receive at this office. We need this record to treat you and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office, whether made by your personal doctor or by other personnel within our office.

This notice advises you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private;

• give you this notice of our legal duties and privacy practices with respect to medical information about you; and

• follow the terms described in this notice.
  

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and provide examples. Not every use or disclosure in a category will necessarily be listed below. However, all of the ways which we are permitted to use and disclose information will fall within one of the categories.

• Treatment - We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other office personnel who are involved in your medical care and treatment. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for you to receive information regarding appropriate meals. Different departments of the office also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the office who may be involved in your medical care after you leave the office, such as family members, clergy or others we may rely upon or ask to assist us in caring for you.
  
  

• Payment - We may use and disclose medical information about you so that the treatment and services which we provide to you at the office, hospital, ambulatory surgery center, nursing home or other site may be billed to and payment may be collected from you and/or your insurance company or other responsible third party. For example, we may need to provide to your health insurance plan information about the services which we provided to you at the office, hospital or ambulatory surgery center, so that your health plan will pay us or reimburse you for the services. We may also tell your health insurance plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
  
  

• Health Care Operations - We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services that we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
  
  

• Appointment Reminders - We may use and disclose medical information in connection with our efforts to remind you that you have an appointment. Postcards will be sent to you to remind you to make an appointment or to contact our office. A telephone call will be made to remind you of your appointment. If you are not home, a message will be left on your machine or with whoever answers the phone. If you prefer to be reminded another way, please inform us in writing with specifics about how and where you would like to be contacted (for example, via e-mail, at the office, with voice messaging only). All requests must be written and submitted to Connie Ferrante.
  
  

• Treatment Alternatives - We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, we may use your information to determine whether you qualify for a nutritional counseling program.
  
  

• Health-Related Benefits and Services - We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
  
  

• Ambulatory Surgery Center Registry - We may include certain limited information about you in the ambulatory surgery registry while you are a patient at the ambulatory surgery center. This information may include your name, location in the ambulatory surgery center, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The registry information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the ambulatory surgery center and generally know how you are doing.
  
  

• Individuals Involved in Your Care or Payment for Your Care - We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. For example, a babysitter responsible for the care of a child may be provided certain information about the treatment which we provided to the child. We may also tell your family or friends your condition and that you are in the hospital, ambulatory surgery center or office. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  
  

• Research - Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the office. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.
  
  

• As Required By Law - We will disclose medical information about you when required to do so by federal, state or local law.
  
  

• To Avert a Serious Threat to Health or Safety - We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
  

SPECIAL SITUATIONS

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

• Military and Veterans - If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  
  If you are a member of the Armed Forces, we may disclose medical information about you to the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is necessary for the Department of Veterans Affairs to determine whether you are eligible for certain benefits.
  
  

• Workers' Compensation - We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
  
  

• Public Health Risks - We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;

• To report births and deaths;

• To report child abuse or neglect;

• To report reactions to medications or problems with products;

• To notify people of recalls of products they may be using;

• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and

• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
  
  

• Health Oversight Activities - We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  
  

• Lawsuits and Disputes - If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if required by law or if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
  
  

• Law Enforcement - We may release medical information if requested by a law-enforcement official acting pursuant to valid legal authority.
  
  

• Coroners, Medical Examiners and Funeral Directors - We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
  
  

• National Security and Intelligence Activities - We may release medical information about you to authorized federal officials for intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
  
  

• Inmates - If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be 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.
  
  

• Emergencies - We may use or disclose your medical information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably possible after the delivery of treatment. If you doctor or another doctor in the practice is required by law to treat you and the doctor has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your medical information in order to treat you.
  
  

• Communication Barriers - We may use and disclose your medical information if your doctor or another doctor in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclose under the circumstances.
  

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy - You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; medical information that is subject to law that prohibits access to medical information.
  
  To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Connie Ferrante. If you request a copy of the information, we may charge a fee as permitted by state law for the costs of copying, mailing or other supplies associated with your request.
  
  We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the office will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

• Right to Amend - If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the office.
  
  To request an amendment, your request must be made in writing and submitted to Connie Ferrante. In addition, you must provide a reason that supports your request.
  
  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

• Is not part of the medical information kept by or for the office; or is not part of the information which you would be permitted to inspect and copy; or

• Is accurate and complete.
  
  

• Right to an Accounting of Disclosures - You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
  
  To request this list or accounting of disclosures, you must submit your request in writing to Connie Ferrante. Your request must state a time-period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
  
  

• Right to Request Restrictions - You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had.
  
  

• We are not required to agree to your request. If your doctor believes it is in your best interest to permit the use and disclosure of your medical information, then your medical information will NOT be restricted. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Connie Ferrante. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
  
  

• Right to Request Confidential Communications - You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
  
  To request confidential communications, you must make your request in writing to Connie Ferrante. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to a Paper Copy of This Notice - You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
  
  You may obtain a copy of this notice at our web site, http://www.brookhaveneye.com.
  
  To obtain a paper copy of this notice, contact Connie Ferrante.
  

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are seen at the office for treatment or health care services as an outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with the office, contact Connie Ferrante, office manager at (631) 475-3355. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.