Privacy Notice

At Homosassa Eye Clinic, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice.

The law permits us to use or disclose your health information to those involved in your treatment.  For example, a review of your file by a specialist doctor whom we may involve in your care. We may use or disclose your health information for payment of your services. For example we may send a report of your progress to your insurance company or even give your insurance company personal information in order to acquire an authorization for services. We may use or disclose your health information for our normal  healthcare operations. For example, one of our staff will enter your information into our computer.  We may use or disclose your health information when calling in prescriptions to a pharmacy. We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone. In an emergency, we may disclose your health information to a family member or another person responsible for your care. We may release  some or all of your health information when required by law. If this practice is sold, your information will  become the property of the new owner. Except as described above, this practice will not use or disclose  your health information without your prior written authorization. You may request in writing that we not use  or disclose your health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. You have the right to see or even transfer copies of your health information to another practice. Give us written request regarding the information you want to see or have sent and  we will mail or fax it for you.

You have the right to receive a copy of this notice. If we change any of the details of this notice, we will  notify you of the changes in writing. If you have a question or complaint in regards to our privacy practices please contact our Privacy Officer, Sherry Walker, at 352-628-3029.

I have received a copy of the Homosassa Eye Clinic Notice of Privacy Practices.

Date:____________ 

Signed_______________________________________

Print Name:_______________________________

If signing as a parent or guardian, please note the name of the patient:____________________________________