NOTICE OF PRIVACY PRACTICES

Scott D. Peterson O.D.

3988 Washington Blvd.

Ogden UT 84403

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.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPTIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care options. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you: testing or examining your eyes: prescribing glasses, contact lenses, or eye medications and faxing them to be filled: referring you to another doctor for eye care or low vision aides or services: getting copies of your health information from another professional that you may have seen before us. We may also use information to obtain payment for services such as from your insurance company. 

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form”. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the form, we cannot make the disclosure. If you do sign one, you may revoke it at any time unless you have already acted in reliance upon it. Revocations must be in writing.

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, payment or health care options. 

            Ask us to communicate with you in a confidential way.

            Ask to see or to get photocopies of your health information.

            Ask us to amend your health information if you think that it is incorrect or incomplete.

            Get a list of the disclosures that we have made of your health information within the past 6 years.

Our office is pleased to offer you convenient, secure access to information from your eye care records through an online portal. Participation is completely optional, if you are interested, we can give you your login information at your request.

If you have any further questions about the privacy of your health information, you can contact Emilee Cutler at our office.

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 complaint to our office ATTN: Cheryl Taylor. If you prefer, you can discuss your complaint in person or by phone.

ACKNOWLEDGEMENT OF RECEIPT

I Acknowledge that I received a copy of “Notice of Privacy Practices” from Scott D. Peterson, O.D.

Patient Name________________________________________________________________­­­­_

Signature_____________________________________________         Date_______________

Effective as of 7/2019