Notice of Privacy Practices

Eyeballs
621 5th Ave N, Suite B
Seattle, WA 98109
(206) 217-2015

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 health care 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 the office contact person at the address, fax of e-mail shown at the beginning of this notice.
• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal e-mail 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 the office contact person at the address, fax or e-mail shown at the beginning of this notice.
• 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. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instruction about how to get an impartial review of our denial if one is legally available. By law, we can have on 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or receive photocopies of your health information, send a written request to the office contact person at the address, fax or e-mail shown at the beginning of this notice.
• 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 of the date the request was received. We will send the corrected information to persons who we know received 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 our rebuttal is included in your health information, we will forward it 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. If you wish to amend your health information, send a written request to the office contact person at the address, fax or e-mail shown at the beginning of this notice.
• 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). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations, disclosures with your authorization, incidental disclosure, disclosures required by law 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 the office contact person at the address, fax or mail shown at the beginning of this notice.
• Get additional paper copies of this “Notice of Privacy Practices” upon request. It does not matter whether you got one electronically or in paper form already.

If you want additional paper copies, send a written request to the office contact person at the address, fax or e-mail 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 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 notice in our office, have copies available in our office, and post it on our web site.

Complaints

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or 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 request to the office 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 the office contact person at the address of phone number shown at the beginning of this notice. More information can also be found at www.hhs.gov/ocr/privacy