NOTICE OF PRIVACY PRACTICES

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.John D. Zdral, M.D., Inc./ Date of Last Revision:
John D. Zdral Optical, Inc. \t Effective Date: April 14, 2003

NOTICE OF PRIVACY PRACTICES

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.

OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION:

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We need a record of your care and services to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways in which we may use and share your protected health information about you and certain obligations we maintain regarding the use and disclosure of this information. It also describes your rights.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU:

For Treatment: We may use or disclose your protected health information to a physician or other health care provider, pharmacy, nursing home (if you reside in one), family member, or others who may provide treatment or services to you or who are involved in your care. For example, we may disclose protected health information regarding surgery or other treatment options or for the coordination of care to other appropriate office personnel or regarding prescriptions or refills.

For Payment: We may use or disclose your protected health information to obtain payment for services we provide to you. For example, we may need to share protected health information about you to insurance companies or other payors for services you have received or are about to receive from us. We may also be required to share protected health information to confirm eligibility and/or to verify that certain services are a covered benefit through your insurance carrier(s).

For Healthcare Operations: We may use or disclose your protected health information for our health care operations. For example, quality assessment and improvement, training and evaluation of health care professionals, accreditation, certificates, licenses and credentialing, and determining premiums and other costs of providing health care.

Appointments and Recall Reminders: We may use or disclose your protected health information to remind you of future appointments or to remind you that you are due for an appointment. For example, we may mail post cards, call you by phone, leave phone messages, fax you or mail other correspondence. We may also request that you sign-in upon arriving for your appointment on a ?Sign-In Log?.

SPECIAL SITUATIONS:

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

To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required by Law: We may disclose protected health information about you when required to do so by federal, state or local law.

Research: We may use and disclose protected health information about you for research projects that are subject to a special approval process. We will ask for your permission if: (1.) the researcher will have access to your name, address or other information that reveals who you are, or (2.) if the researcher will be involved in your care at our office.

Organ and Tissue Donation: If you are an organ or tissue donor, we may release protected health information to organizations that handle procurement, as necessary.

Military, Veterans, National Security and Intelligence: If you are or were a member of the armed forces or part of the intelligence communities, we may be required to release protected health information about you to the appropriate military, national security or intelligence authorities.

Workers? Compensation: In order to comply with workers? compensation laws, we may use and disclose your protected health information. For example, we may communicate your health information regarding a work-related injury or illness to claims administrators, insurance carriers, and others responsible for evaluating your claim for workers? compensation benefits.

Public Health Activities: Public policy may require us to disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect; to report births and deaths; to report reactions to medications, recalls or problems with products; or to notify appropriate government authorities if we believe a patient has been the victim of abuse, neglect or domestic violence. We may also, if authorized by law to do so, disclose protected information to notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Health Oversight Activities: We may disclose your protected health information to oversight agencies for audits or investigations.

Lawsuits and Other Legal Disputes: We may disclose your protected health information in responding to a court or administrative order, a subpoena or a discovery request, or to the extent permitted by law without your authorization, for example, to defend a lawsuit or arbitration.

Law Enforcement: We may disclose protected health information to authorized officials for law enforcement purposes, for example, to respond to a search warrant, report a crime on our premises, or help identify or locate someone.

Coroners, Medical Examiners and Funeral Directors: We may release protected health information about you to a coroner or medical examiner to help determine identity or cause of death.

Communications with Family and Others: There may be times when it is necessary to disclose your protected health information to a family member or other person involved in your care because there is an emergency, you are not present, or you lack the decision-making capacity to agree or object. In those instances, we will use our professional judgment to determine if it is in your best interest to disclose such information. If so, we will limit the disclosure to the information that is directly relevant to the person?s involvement with your health care. For example, we may allow someone to pick up a prescription for you or to clarify surgery questions.

OTHER USES OF PROTECTED HEALTH INFORMATION:

Other uses and disclosures of your protected health information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION:

Right to Request Confidential Communications: You have the right to request that we communicate with you about your medical matters in a certain way or at a certain location. For example, you may ask that we leave messages regarding your care only with certain people or call you only at a certain location. Requests must be submitted in writing to our Compliance Officer in a clear and concise manner and must be signed and dated. We will make every effort to comply with this request.

Right to Inspect, Copy and Amend: You have the right to review and copy your medical records by submitting your request in writing to our Compliance Officer. Ask our receptionist for the name of our Compliance Officer. A fee may be charged for our costs associated with your request. Requests to amendment your health care information must be submitted in writing, along with your intended amendment and a reason that supports why you think this should be done. The request must also be signed and dated by you.

We may or may not make the changes you request, but will include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information.

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations, or to someone who is involved in your care or the payment for your care (a family member or friend). For example, you could ask that we not use or disclose information about a particular treatment you received.

We are not required to agree with your request and we may not be able to comply with your request. Requests must be submitted in writing to our Compliance Officer. Requests must indicate what information you want to limit; whether you want to limit our use, disclosure or both; and to whom you want the limits to apply (e.g., disclosures to your children, parents, spouse, etc.).

Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of protected health information not related to treatment, payment or healthcare operations. You must submit your request in writing. Your request must state a time period not longer than six (6) years prior to the date of your request, and can not include dates prior to the compliance date of April 14, 2003. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Receive a Copy of this Notice: You have the right to receive a paper copy our Notice of Privacy Practices.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the waiting room. The notice will contain, on the first page, in the top right-hand corner, the date of the last revision and effective date. In addition, each time you visit our practice for treatment or health care services, you may request a copy of the current notice in effect.

QUESTIONS AND COMPLAINTS:

If you have any questions about this notice or if you think we may have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.