Privacy Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION AOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

USES AND DISCLOSURES

TREATMENT. Your health information may be used by staff members or disclosed to other healthcare professionals for the
purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of
laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment
or who may be consulted by staff members.

PAYMENT. Your health information may be used to seek payment from your health plan, from other sources of coverage
such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health
plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

HEALTHCARE OPERATIONS. Your health information may be used as necessary to support the day-to-day activities and
management of Retina and Vitreous of Texas, PLLC. For example, information on the services you received may be used to
support budgeting and financial reporting, and activities to evaluate and promote quality.

LAW ENFORCEMENT. Your health information may be disclosed to law enforcement agencies to support government audits
and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

PUBLIC HEALTH REPORTING. Your health information may be disclosed to public health agencies as required by law. For
example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purposes other
than those listed above requires your specific written authorization. If you change your mind after authorizing a use or
disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke
the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your
decision to revoke your authorization.

Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing
purposes when financial remuneration is involved. We may not sell your protected health information without your
authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We
will not use or disclose any of your protected health information that contains genetic information that will be used for
underwriting purposes.

ADDITIONAL USES OF INFORMATION

APPOINTMENT REMINDERS. Your health information will be used by our staff to send you appointment reminders.

INFORMATION ABOUT TREATMENTS. Your health information may be used to send you information on the treatment and
management of your medical condition that you may find interesting. We may also send you information describing other healthrelated products and services that we believe may interest you.

FUNDRAISING. We will not use your protected information for fund-raising efforts unless approved by you in writing for the specific
fund-raising effort.

MARKETING. We will not use your protected information for marketing efforts unless approved by you in writing for the specific
marketing effort.

INDIVIDUAL RIGHTS

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect a copy of your protected health information
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice

RETINA AND VITREOUS OF TEXAS, PLLC’S DUTIES

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy
practices. We also are required to abide by the privacy policies and practices outlined in this notice. In the event of a breach of
unsecured protected health information, if your information has been compromised, it is our duty to notify you.

RIGHT TO REVISE PRIVACY PRACTICES

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and
practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most
recently revised notice on any office visit.

The revised policies and practices will be applied to all protected health information we maintain.

REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require
that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your
records by contacting our Medical Records department or the Privacy Officer. Your request will be reviewed and will generally be
approved unless there are legal or medical reasons to deny the request.

COMPLAINTS

If you would like to submit a comment or complain about our privacy practices, you can do so by sending a letter outlining your
concerns to:

Privacy Officer
Retina and Vitreous of Texas, PLLC
2727 Gramercy Suite 200
Houston, TX 77025

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the
cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

This effective date of this Notice of Privacy Practices is 11/13/2014