Michigan Focal Point PLLC

Notice of Privacy Practices

Effective Date: 03/04/2024

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

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) requires all health care records and other
individually identifiable health information (Protected Health Information-hereafter known as PHI) used or
disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives
you, the patient, significant new rights to understand and control how your health information is used. HIPAA
provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have
prepared this explanation of how we are required to maintain the privacy of your health information and how we
may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your health care records for the
purposes of treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include routine vision exams, punctual occlusion, glaucoma testing, contact lens insertion and removal instructions, etc.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your vision plan for your vision services.
Health Care Operations include the business aspect of running our practice, such as conduction quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or
provide you with information about treatment options or other health-related services including release of
information to friends and family members that are directly involved in your case or who assist in taking care of
you. We will use and disclose your PHI to order contact lens trials or other items specific to your needs and
prescription. We will disclose your PHI when we are required to do so by federal, state, or local law. We may
disclose your PHI to public health authorities that are authorized by law to collect information, to a health oversight
agency for activities authorized by law included but not limited to: response to a court or administrative order, if
you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful
process by another party involved in the dispute, but only if we have made an effort to inform you of the request or
if the request to obtain an order protecting the information the party has requested. We will release your PHI if
requested by a law enforcement official for any circumstance required by law. We may release your PHI to a
medical examiner or coroner to identify a deceased individual or to identify cause of death. If necessary, we may
also release information in order for funeral directors to perform their jobs. We may release PHI to organizations
that handle organ, eye, or tissue procurement or transplantation if you are an organ donor. We may disclose your
PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of
another individual or the public health. Under these circumstances, we will only make disclosures to a person or
organization able to prevent the treat. We may disclose your PHI to federal officials for intelligence and national
security activities authorized by law. We may disclose your PHI to federal officials in order to protect the President,
other officials or foreign heads of state, or to conduct investigations. We may disclose your PHI to correctional
institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. We
may release your PHI for workers’ compensation and similar programs.

Disclosure for these purposes would be necessary:

(a) for the institution to provide health care services to you,
(b) for the safety and security of the institution, and/or
(c) to protect your health and safety or the health and safety of other individuals or the public.

Any other uses and disclosures will be made only with your written authorization. You may revoke such
authorization in writing, and we are required to honor and abide by that written request, except to the extent that
we have already taken actions relying on your authorization.

You have certain rights to your PHI, which you can exercise by presenting a written request to our Privacy Officer at
the practice address listed below:

The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosure to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to request to receive confidential communications of PHI from us by alternative means or at alternative locations.
The right to access, inspect, and copy your PHI.
The right to request an amendment to your PHI.
The right to receive an accounting of disclosures of PHI outside of treatment, payment, and health care Operations.
The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain
the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECTED HEALTH INFORMATION.

We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to
change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PHI that
we maintain. Revisions to our notice of Privacy Practices will be posted on the effective date and you may request a
written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of
Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will
not retaliate against you for filing a complaint.

For more information about Privacy Practices, please contact:
Michigan Focal Point PLLC. 39500 Ford Rd Canton, MI 48187

For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775 (toll-free)
By signing below, I acknowledge that I have received Michigan Focal Point PLLC’s Privacy Notice.

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SIGNATURE DATE