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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY

Your Information. Your Rights. Our Responsibilities.

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

Your Rights

You have the right to:

• Get a copy of your health and claims records

• Correct your health and claims records

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends

• Provide disaster relief

• Market our services

Our Uses and Disclosures

We may use and share your information as we:

• Help manage the health care treatment you receive

• Run our organization

• Pay for your health services

• Administer your health plan

• Help with public health and safety issues

• Do research

• Comply with the law

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

Your Rights

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. There may be a fee.

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• You can ask for a list of the times we’ve shared your health information,who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

• You can file a complaint, if you feel we have violated your rights, by contacting us at 480-812-2211 and asking for Tiffany or Stacie. You may also do so by email at Stacie@sonorandeserteye.com or by filling out a complaint form from the front desk and sending it to

ATTN: Stacie Coggon

2211 E. Pecos Road Ste. 1

Chandler, AZ 85225

 All complaints must include the name of the offending person and the acts or omissions believed to be in violation. Complaints must be filed within 180 days of violation.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

Our Uses and Disclosures

Help manage the health care treatment you receive

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Pay for your health services

We can use and disclose your health information as we request payment for your health services.

Administer your plan

We may disclose your health information to your health plan sponsor for plan administration.

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Other Instructions for Notice

• Effective Date of this Notice – September 1, 2016

• Contact Stacie Coggon 480-812-2211 or Stacie@sonorandeserteye.com

• We do not sell any personal information

• You may view your patient information on www.revolutionPHR.com with a username and password we provide for you. If you have not received one you may request one from the front desk.