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OPHTHALMOLOGY ASSOCIATES
Notice of Privacy Practices
The protection of your health information is important to us at Ophthalmology
Associates. We have available to you a comprehensive version of our Notice of Privacy
Practices if you wish to read it in its entirety. During the appointment check-in process
you will be asked to sign a medical record document acknowledging receipt of the Notice
of Privacy Practices. The delivery of your health care services will in no way be
conditioned upon your signed acknowledgement. If you have any questions about the
Notice of Privacy Practices, please notify an Ophthalmology Associates physician or staff
member.
Please Read the Following
I have been provided the opportunity to read the Notice of Privacy Practices at
Ophthalmology Associates.
I understand that Ophthalmology Associates is committed to treating and using protected
health information about me responsibly. In using this information, this office will
comply with all state and federal laws pertaining to your privacy rights, including the
Privacy and Security protections provided to you by the Health Insurance Portability and
Accountability Act (“HIPAA”).
I understand that my health record is the physical and legal property of Ophthalmology
Associates, but the information belongs to me. I may have access to inspect, amend or
obtain a copy of my health information. Costs will incur for copies of my records, and
appointments must be made with the Privacy Officer to inspect, access, or amend my
health information.
I understand that Ophthalmology Associates is required to maintain the privacy of my
health information. Ophthalmology Associates will require my authorization to release
my health information to outside sources with the exception of disclosures for purposes
of Treatment, Payment, and Healthcare Operations. Your authorization will need to
be in writing and it will be specific to the disclosure requested. Your authorization for
use and disclosure of information, with the exceptions as referenced above, may be
revoked in writing at any time. Please notify this office if you ever decide to revoke your
consent.
If you believe that your privacy rights have been violated, you may submit a written
complaint to our HIPAA Privacy Officer at the address below:
Ophthalmology Associates
1201 Summit Avenue
Fort Worth, TX 76102
Attn: Privacy Officer
Notice Effective Date: April 1, 2003
Notice Revision Date:
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