BETZ OPHTHALMOLOGY ASSOCIATES

NOTICE OF PRIVACY PRACTICES

As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF BETZ OPHTHALMOLOGY ASSOCIATES MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION.

We must provide you with the following information:
How we may use and disclose your PHI (Protected Health Information)
Your privacy rights in your PHI
Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your personal information that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practice. Any revision or amendment to this notice will be effective for all of our records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current notice in our office in a visible location at all times, and you may request a copy of our most recent notice at any time.

If you have questions about this notice please contact Betz Ophthalmology Associates Privacy Officer at 3 Hospital Drive, Lewisburg, PA. 17837; phone 570-524-4473.

The following categories describe the different ways in which we may use and disclose health information. Your PHI may be used and disclosed by your provider, our office staff and others outside of our office that are involved in you care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay health care bills and to support the operation of the provider's practice.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. For example, we may ask you to have various testing done and we may use the results to help reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of our employees who work for the practice, including but not limited to, our physician, optometrist, opticians, nurses, technicians, office manager and secretaries, may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents.

In addition we may disclose your PHI to another provider such as a specialist or testing facilities who, at the request of your provider, become involved in your care.

Payment: Our practice may use and disclose your PHI in order to bill and collect payment for services and products you may receive from our office. This can include activities that your health plan may undertake before it approves or pays for the health care services, determining eligibility or coverage for insurance benefits, reviewing services provided for medical necessity, and/or undertaking utilization review activities. For example, we may contact your health insurance carrier to certify that you are eligible for benefits and for what range of benefits, and we may provide your health insurance carrier with details regarding your treatment to determine if your insurer will cover your treatment. We also may use and disclose your PHI to obtain payment from other third parties and to bill directly for services and supplies.

Health Care Operations: Our practice may use and disclose your PHI to operate our business. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, marketing, and for other business activities. For example your name will be called in the waiting room when it is time for your physician to see you. We may disclose your PHI to contact you to remind you of your appointment.

Business associates perform various activities such as billing, transcription and collections for our office. We will share your PHI with business associates whenever appropriate. A written contract with the business associates will outline the terms that will protect the privacy of your PHI. We might use or disclose your PHI to discuss with you information about treatment alternatives or other health related services.

Disclosure Required By Law: Our practice would use and disclose your PHI when we are required by federal, state or local law authorities.

Release of Information to Family/Friends: Our practice may release your PHI to a family member or friend that is involved in your care or who assists in taking care of you. For example, a parent or guardian may ask that a family member go to the pharmacy and pick up a prescription. In this case, the family member may have access to another family member's medical information.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

We may use and disclose your PHI in the following instances. You have the opportunity to agree to object to all or part of your PHI being used or disclosed. If you are not able to agree or object to the use or disclosure of your PHI, then your physician will, using professional judgment, determine whether the use is in your best interest. In any event, only the PHI that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare: Unless you have objections, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person's involvement in your health care. If you are unable to object to such a disclosure, we may disclose such information if we determine that it is in your best interest. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person responsible for your care. Finally, we may disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies: We may use or disclose your PHI in an emergency situation. If this happens, your provider will try to obtain your consent as soon as reasonably practicable after delivery of treatment. If your provider or another provider in the practice is required by law to treat you and the provider has attempted to obtain our consent but is unable he or she may still use your PHI to treat you.

Communication Barriers: We may use and disclose your PHI if your provider or another provider in the practice attempts to obtain consent but is unable to do so due to substantial communication barriers and the provider determines, using professional judgment, that you intend to under the circumstances.

Uses and Disclosures of PHI Based upon Your Written Authorization

Other uses and disclosures of your PHI will be made with your written authorization, unless otherwise permitted or required by law as described below. You can revoke this authorization in writing at any time, except to the extent that your provider or the provider's practice has taken an action in reliance on the authorization. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

Other Permitted and Required Uses and Disclosures that may be made without your Consent, Authorization or Opportunity to Object

Public Health: Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• maintaining vital records, such as births and deaths
  reporting child abuse or neglect
• preventing or controlling disease, injury or disability
• notifying a person regarding potential exposure to a communicable disease
• notifying a person regarding a potential risk for spreading contracting a disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled
• notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence) however we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.
• notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Required By Law: We may use or disclose your PHI to the extent that law requires the use or disclosure. The use of disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to a court or administrative tribunal order (to the extent such disclosure is expressly authorized). We also may disclose your PHI in 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 to obtain an order protecting the information the party has requested.

Law Enforcement: We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include.

• legal process and otherwise required by law
• limited information request for identification and location purposes
  pertaining to victims of a crime
• suspicion that death has occurred as a result of criminal conduct
• in the event that a crime occurs on the premises of the practice
• medical emergency (not on the practice's premises) and it is likely that a crime has occurred.

Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose our PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: Our practice may use and disclose our PHI for research in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when our use or disclosure was approved by an Institutional Review Board or a Privacy Board, we obtain the oral or written agreement of a research that the information being sought is necessary for research study. The use of disclosure of your PHI is being used only for the research and the researcher will not remove any of your PHI from our practice or the PHI sought by the researcher only relates to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access to the PHI of the decedents.

Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, tract products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your PHI to authorize federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your provider created or received your PHI in the course of providing care to you.

Worker's Compensation: Our practice may release your PHI for worker's compensation and similar programs.

Required Uses and Disclosures - Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you.

Confidential Communications: You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, but not leave a message on the answering machine. We will accommodate reasonable requests. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You have the right to request a restriction of your PHI: This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restrictions and to whom you want the restriction to apply.

Your provider is not required to agree to a restriction. If provider believes it is in the best interest to permit use and disclose of your PHI, your PHI will not be restricted. If your provider does not agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your provider. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Betz Ophthalmology Associates Attn: Privacy Officer, 3 Hospital Drive, Lewisburg, PA. 17837. Your request must describe in a clear and concise fashion the following information. The information you wish restricted, whether you are requesting to limit our practice's use, disclosure or both, and to whom you want the limits to apply.

You have the right to inspect and copy your PHI: This means you may inspect and obtain a copy of PHI about you that is contained in your medical record. A medical record contains medical and billing records and any other records that your provider and the practice use for making decisions about you.

Under federal law, however, you may not inspect or copy the following records, psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administration action or proceeding, and PHI that is subject to law that prohibits access to PHI. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You must submit your request in writing to Betz Ophthalmology Associates Attn: Privacy Officer 3 Hospital Drive, Lewisburg, PA, 17837 in order to inspect and/or obtain a copy of your medical record. Our practice will charge a fee for the cost of copying, mailing, labor and supplies associated with your request.

You may have the right to have your provider amend your PHI - This means you may request an amendment of PHI about you in your medical record for as long as we maintain it. To request an amendment, your request must be made in writing and submitted to Betz Ophthalmology Associates Attn: Privacy Officer 3 Hospital Drive, Lewisburg, PA, 17817. You must provide us with a reason that supports your request for amendment.

In certain cases, we may deny your request for an amendment. We may deny your request if you ask us to amend information that is our opinion accurate and complete, not part of the PHI kept by or for the practice, not part of the PHI which you would be permitted to inspect and copy; or not created by our practice, unless the individual or entity that created the information is not available to amend the information.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have any questions about amending your medical records.

You have the right to receive an accounting of certain disclosures we have made, if any of your PHI. This right applies to disclosures for purposes other that treatment, payment or healthcare operations as described in this Notice of Privacy Practices. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.

An account of disclosures is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment or operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the physician sharing information with the billing department using your information to file insurance claims. In order to obtain an accounting of disclosures, you must submit your request in writing to Betz Ophthalmology Associates Attn: Privacy Officer 3 Hospital Drive, Lewisburg, PA, 17837. All requests for an account of disclosures must state a time period, which may not be longer that 6 years from the date of disclosure and may not include dates before April 14, 2003. Our office will notify you of the cost involved with additional requests, and you may withdraw your request before you incur any cost.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by our office. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Contact Barbara Heath at 570-524-4473 for further information about the complaint process.

Your have the right to obtain a paper copy of this notice from our office upon request, even if you have agreed to accept this notice electronically.

Again if you have any questions regarding this notice of our health information privacy policies, please contact Barbara Heath, Privacy Officer, at 570-524-4473.