Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

If you have any questions about this notice please contact Dana Allbritton, Privacy Officer, 386.788.6696 or 407.333.5111

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/03, and will remain in effect until we replace it. We reserve the right to change our privacy practices and applicable law permits the terms of this Notice at any time, provided such changes. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

The information provided in this Notice applies to Filutowski Eye Institute and its associated Surgical Centers.

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment, and health care operations. For example:

• Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you.
• Payment: We may use or disclose your health information to obtain payment for services we provide to you.
• Health Care Operations: We may use or disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
• Your Authorization: In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in the Notice.
• To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.
• Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your locations, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
• Marketing Health Related Services: We will not use your health information for marketing communications without your written authorization.
• Required By Law: We may use or disclose your health information when we are required to do so by law.
• Abuse or Neglect: We may use or disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
• National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
• Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
• Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• Workers Compensation: Pursuant to Florida Law, we may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks: We may disclose medical information about you for public health activities: To prevent or control disease, injury or disability; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Disaster Relief Organizations: In the event of a disaster, we may share protected health information with Disaster Relief organizations to coordinate care of the patient and/or locate family members.

Patient Rights

Access

You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies, such as an electronic copy if the records are maintained electronically. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. Florida law allows physicians to charge a reasonable copying fee of $1.00 per page for the first 25 pages and $0.25 for each page in excess of 25 (Florida Administrative code rule 64B8-10.003).

Disclosure Accounting

You have the right to receive a list of instances in which our business associates or we disclosed your health information for purposed, other than treatment, payment, health care operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction

You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication

You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment

You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.

Electronic Notice

If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive a paper copy of this Notice.

Notification of a Breach

You have the right to be notified if a breach of confidentiality occurs that involves your protected health information.

Self-Pay

You have the right to request that your medical information not be shared with your medical insurance carrier if you pay out of pocket for services rendered.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Filutowski Eye Institute or with the Secretary of the Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW, Atlanta GA 30303-8909.

To file a complaint with Filutowski Eye Institute you may contact our Compliance Officer at 407.333.5111 or 386.788.6696.

All complaints must be submitted in writing to:

Dana Allbritton, Privacy Officer Filutowski Eye Institute

110 Yorktowne Drive, Daytona Beach, FL 32119, or

1070 Greenwood Blvd., Lake Mary, FL 32746

Fax: 386.788.2219 Daytona Beach or 407.333.2434 Lake Mary

E-Mail: dana.allbritton@filutowski.com

You will not be penalized for filing a complaint

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

If protected health information is to be released for the purpose of treatment/continuation of care, it is this practice’s preference to send records directly to your health care provider rather than to release them to the patient. We will release your records to you if requested, but for the purpose of keeping your protected health information secure and limiting unauthorized disclosures, direct communication between health care providers is preferred and strongly advised.

Please understand that complete and absolute privacy is virtually impossible; your very presence in our facility implies that you are seeking treatment for an eye condition. It is our policy to provide the highest level of privacy to our patients that we are able, but there will be times when testing, procedures and conversations with staff may take place where they can be observed or overheard by non-staff members (i.e. other patients and their companions). If you desire a greater level of privacy, it is your responsibility to request it. You will be given the opportunity to make this request before any treatment or conversations take place and we will do our best to accommodate the request.