We are absolutely committed to preserving the privacy of your health information.


The Vision Center of West Phoenix, P.L.L.C. is committed to preserving the privacy of your health information. In fact, we are required by law to do so for any information created or kept by us. We are also required to provide you with this Notice describing our legal duties and our practices concerning your health information. For the rest of this Notice, TVC will refer to all services, service areas, and workers of The Vision Center of West Phoenix.


This Notice tells you how TVC uses and discloses the health information that you have given us or that we have learned from you when you were a patient in our

system. It also tells you about our responsibility to you and how we can and cannot use your health information. Note: When we use the words your health information, we mean any information that you have given us about you and your health, as well as information that we have gathered while we have taken care of you (including health information provided to TVC by those outside TVC). TVC will follow this Notice of Privacy Practices and any future changes to the Notice that we are required or authorized by law to make. We have the right to change this Notice and to make the revised or changed Notice effective for health information we already have about you, as well as any information we receive in the future. We will have a copy of the current Notice with an effective date in all clinical locations.

The health information practices listed in this Notice will be followed for all TVC practices, activities and locations. This includes the practices of:

All TVC employees, volunteers, students, clinical interns and service providers, including clinicians, who have access to health information.

Any health care professional authorized to enter information into your TVC health record.

Any nonTVC clinicians who might otherwise have access to your health information created or kept by TVC, as a result of, for example, their call coverage for TVC


The people listed above will share your health information with each other for purposes of treatment, payment, and healthcare operations, as further described in this Notice.


1. Treatment, Payment and Health Care Operations.

The following section describes different ways that we use and disclose health information for treatment, payment and health care operations. For each of those categories, we explain what we mean and give one or more examples. Not every use or disclosure will be noted and there may be incidental disclosures that are a

byproduct of the listed uses and disclosures. The ways we use and disclose health information will fall within one of the categories.

a. For Treatment. We may use your health information to provide you with eye or vision treatment or services. We may disclose your health information to staff optometrist, staff physicians, clinical interns, technicians, and other personnel involved in your health care. We may also disclose your health information to students and interning optometrist who, as a part of their TVC educational programs (and while supervised by optometrist or physicians), are involved in your care. Treatment includes (a) activities performed by office staff, technicians and other types of health care professionals providing care to you or coordinating or managing your care with third parties, (b) consultations with and between TVC providers and other health care providers, and (c) activities of non-TVC providers or other providers covering an TVC practice by telephone or serving as the on-call provider. For example, an optometrist or physician treating you for an infection may need to know if you have other health problems that could complicate your treatment. That provider may use your medical history to decide what treatment is best for you. They may also tell another provider about your condition so that he or she can decide the best treatment for you.

b. For Payment. We may use and disclose your health information so that we may bill and collect payment from you, an insurance company, or someone else for health care services you receive from TVC. Your medical condition or prescription may require that we place an order, request a service or transaction for medical testing, laboratory testing, laboratory services, or custom medical devices. All fees paid in order to initiate the order, service or transaction are non-refundable and nontransferable. The patient is responsible for any cancellation charges, shipping charges, or service charges incurred during the process. In the event it gets turned over to a collection agency, collection fees may be assessed. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment. For example, we may need to give your health plan information about treatment you received at TVC so your health plan will pay us or reimburse you for the treatment.

c. For Health Care Operations. We may use and disclose your health information in order to run the necessary administrative, educational, quality assurance and

business functions at TVC. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about patients to help us decide what additional services we should offer, how we can improve efficiency, or whether certain treatments are effective. Or we may give health information to doctors, nurses, technicians, or health profession students for review, analysis and other teaching and learning purposes.

2. Special Circumstances. Treatment, payment and health care operations at TVC include uses and disclosures in the circumstances listed below.

a. Appointment Reminders. We may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or services.

b. Treatment Alternatives and Health Related Products and Services. We may use and disclose your health information in order to allow someone to contact you about possible treatment options or alternatives, or health related products or services that may be of interest to you. For example, a TVC provider may contact you with information about a health service that may benefit you after your discharge from the clinic.

c. Fundraising Activities. We may use and disclose a limited amount of your health information internally, to contact you to raise money for TVC community

service activities. The health information released for these fundraising purposes will include your name, address, phone number and dates on which you received

service at TVC. Any fundraising communications you receive from TVC will include information on how you can elect not to receive any further fundraising communications from TVC.

3. Uses and Disclosures You Can Limit

a. Clinic Directory. Unless you notify us that you object, we may include certain information about you in the clinic directory in order to respond to inquiries from friends, family, clergy and others who inquire about you when you are a patient in the clinic. Specifically, your name and your general condition (e.g., good, fair, serious, critical) may be released to people who ask for you by name.

b. Family and Friends. Unless you notify us that you object, we may provide your health information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We may do this if you tell us we can do so, or if you know we are sharing your health information with these people and

you dont stop us from doing so. There may also be circumstances when we can assume, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your information to your spouse if your spouse comes with you into the exam room during treatment.

Also, if you are not able to approve or object to disclosures, we may make disclosures to a particular individual (such as a family member or friend), that we feel are in your best interest and that relate to that persons involvement in your care. We may also make similar professional judgments about your best interests that allow another person to pick up such things as prescriptions, medical supplies and imaging documents.


We may use or disclose your health information without your permission in the following circumstances, subject to all applicable legal requirements and limitations:

1. Required By Law: As required by federal, state, or local law.

2. Public Health Risks: For public health reasons in order to prevent or control disease, injury or disability; or to report suspected abuse or neglect, non-accidental

physical injuries, reactions to medications or problems with products.

3. Health Oversight Activities: To a health oversight agency for audits, investigations, inspections, licensing purposes, or as necessary for certain government

agencies to monitor the health care system, government programs, and compliance with civil rights laws.

4. Lawsuits and Disputes: Law Enforcement: In response to a subpoena or a court or administrative order, if you are involved in a lawsuit or a dispute, or in response to a court order, subpoena, warrant, summons or similar process, if asked to do so by law enforcement.

5. Coroners, Medical Examiners and Funeral Directors: To a coroner or medical examiner, (as necessary, for example, to identify a deceased person or determine the cause of death) or to a funeral director, as necessary to allow him/her to carry out his/her activities.

6. Organ and Tissue Donation: To organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate a donation and transplantation.

7. Research: For research purposes under certain limited circumstances. Research projects are subject to a special approval process. Therefore, we will not use or

disclose your health information for research purposes until the particular research project, for which your health information may be used or disclosed, has been approved through this special approval process.

8. Serious Threat to Health or Safety; Disaster Relief: To appropriate individual(s)/organization(s) when necessary (i) to prevent a serious threat to your health and

safety or that of the public or another person, or (ii) to notify your family members or persons responsible for you in a disaster relief effort.

9. Military and Veterans: As required by military command or other government authority for information about a member of the domestic or foreign armed forces.

10. National Security; Intelligence Activities; Protective Service: To federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including activities related to the protection of the President, other authorized persons or foreign heads of state, or related to the conduct of special investigations.

11. Workers Compensation: To your employer via a workers compensation or similar workrelated injury program.

12. Inmates: To a correctional institution (if you are an inmate) or a law enforcement official (if you are in that persons custody) as necessary (a) for the institution to

provide you with health care; (b) to protect your or others health and safety; or (c) for the safety and security of the correctional institution.


Other than for those purposes identified above in Sections B and C, we will not use or disclose your health information for any purpose unless you give us your specific written authorization to do so. If you give us authorization, you can withdraw this written Authorization at any time. To remove your authorization, deliver a written revocation to TVC(RE: Health Information Management), 9515 West Camelback Road, Suite 110, Phoenix, AZ 85037.If you revoke your Authorization, we will no longer use or disclose your health information as allowed by your written Authorization, except to the extent that we have already relied on your Authorization.


You have certain rights regarding your health information, which we list below. In each of these cases, if you want to exercise your rights, you must do so in writing by completing a form that you can obtain from TVC (RE: Health Information Management), at 9515 West Camelback Road, Suite 110, Phoenix, AZ 85037. In some cases,

we may charge you for the costs of providing materials to you. You can get information about how to exercise your rights and about any costs that we may charge for materials by contacting TVC at (623) 937-1655.

1. Right to Inspect and Copy. With some exceptions, you have the right to inspect and get a copy of the health information that we use to make decisions about your care. For the portion of your health record maintained in our electronic health record, you may request we provide that information to you. If you make such a request, we are required to provide that information for you in 60 days (unless we deny your request for other reasons). We may deny your request to inspect and/or copy in certain limited circumstances, and if we do this, you may ask that the denial be reviewed.

2. Right to Amend. You have the right to amend your health information maintained by or for TVC, or used by TVC to make decisions about you. We will require that

you provide a reason for the request, and we may deny your request for an amendment if the request is not properly submitted, or if it asks us to amend information that (a) we did not create, (unless the source of the information is no longer available to make the amendment); (b) is not part of the health information that we keep; (c) is of a type that you would not be permitted to inspect and copy; or (d) is already accurate and complete.

3. Right to an Accounting of Disclosures. You have the right to request a list and description of certain disclosures by TVC of your health information.

4. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you (a) for treatment,

payment, or health care operations, (b) to someone who is involved in your care or the payment for it, such as a family member or friend, or (c) to a health plan for payment or health care operations purposes when you have paid for the item or service for which the health care provider involved has been paid out of pocket in full. For example, you could ask that we not use or disclose information about a treatment or surgery you had, a laboratory test ordered or a medical device prescribed for your care. Except for the request noted in 4(c) above, we are not required to agree to your request. Any time TVC agrees to such a restriction, it must be in writing and signed by the TVC Privacy Officer or his or her designee.

5. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain

place. For example, you can ask that we only contact you at work or by mail.

6. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice, whether or not you may have previously agreed to receive the Notice



If you have any questions about this Notice, please contact TVC (623) 937-1655. If you believe your privacy rights have been violated, you may file a complaint with TVC or with the Secretary of the Department of Health and Human Services. To file a complaint with TVC, contact TVC at (623) 937-1655. You will not be penalized for filing a complaint. This notice tells you how we may use and share health information about you. If you would like a copy of the TVC notice, please ask your vision care provider.