0 SHOP ONLINE OFFERS INSURANCES PRODUCTS FIND A STORE Book Eye Exam 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. If you have any questions about this Notice of Privacy Practices, please contact our HIPAA Privacy Officer: Email: privacyofficer@cohensfashionoptical.com US Mail: Cohen’s Fashion Optical Attn: Privacy Officer 100 Quentin Roosevelt Blvd | Suite 400 Garden City, New York 11530 Telephone: 516-599-5500 This Notice of Privacy Practices describes how COHEN FASHION OPTICAL, LLC may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or conditions and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice at any time. Any revised Notice of Privacy Practices would be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by emailing at privacyofficer@cohensfashionoptical.com and requesting that a revised copy be sent to you in the mail. A copy of the current Notice of Privacy Practices will be posted on our website at (insert link). USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION Uses and Disclosures of Protected Health Information We may use or disclose your protected health information to third parties including, but not limited to, your insurance company and your other health care providers for treatment, payment or operational purposes without your written authorization, as allowed under law. Treatment We may use and disclose your protected health information to provide, coordinate or manage your health care and any related treatment. This includes the coordination or management of your health care with a third party that already has obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to your optometrist. We also may disclose protected health information to other specialist providers who may be treating you. Payment Your protected health information may be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services or supplies we provide for you, determining your eligibility or coverage for insurance benefits, and undertaking utilization review activities. Health Care Operations We may use or disclose, as needed, your protected health information in order to support our business activities. These activities include, but are not limited to, quality assessment activities, employee review activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to an auditor or accountant for review of our business operations. We may share your protected health information with third party “business associates” that perform various activities for us (e.g., computer consulting company, law firm or other consultants). Whenever an arrangement between us and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about health care alternative products or other health-related benefits, services, offers, programs, and products that may be of interest to you. You may contact our HIPAA Privacy and Security Officer to request that these materials not be sent to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing, except to the extent that Practice has taken an action in reliance on the use or disclosure indicated in the authorization. The following uses and disclosures may be made only with your authorization: Uses and disclosures for marketing purposes; Uses and disclosures that constitute the sale of PHI; Most uses and disclosures of psychotherapy notes (if Practice maintains psychotherapy notes); and Other uses and disclosures not described in the notice Other Permitted and Required Uses and Disclosures That May Be Made With Your Permission or Opportunity to ObjectInformation to your family members A deceased patient’s health information may be disclosed to a distributee, executor or administrator of the decedent as allowed, and in accordance with, applicable law. Other Permitted and Required Uses and Disclosures that may be Made without your Consent or Authorization Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law. Public Health: We may disclose your protected health information for public health activities to a public health authority that is permitted by law to collect or receive the information. The disclosure may be made for the purpose of controlling disease, injury or disability. We also may disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose your protected health information to a governmental agency for activities authorized by law, such as audits, investigations, and inspections. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information 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. Product Monitoring and Recalls: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, and biologic product deviations; to track products; to enable product recalls; to make repairs or replacements, or in connection with post-marketing surveillance, as required by law. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes included (1) legal processes, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on our premises, and (6) medical emergency and it is likely that a crime has occurred. Decedents: Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties. Protected health information does not include health information of a person who has been deceased for more than 50 years. Organ/Tissue Donation: Your health information may be used or disclosed for cadaver organ, eye or tissue donation purposes. Criminal Activity: We may disclose your protected health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety or a person or the public. We also may disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for authorized military purposes, as required by law. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. 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 the federal privacy regulations. YOUR RIGHTS You have the right to inspect and copy your protected health information This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set maintained by us for as long as we maintain the protected health information. We may charge you our standard fee for the costs of copying, mailing or other supplies we use to fulfill your request. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You also may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. In most circumstances, we are not required to agree to a restriction that you may request. However, if you request us to restrict disclosures to health plans that we would normally make as part of payment or health care operations, we must agree to that restriction if: (a) the disclosure is for the purpose of carrying out payment or health care operations (and is not otherwise required by law), and (b) the protected health information relates to health care which you have paid out of pocket in full. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction in writing to the HIPAA Privacy and Security Officer. Your request must include (a) the information you wish restricted; (b) whether you are requesting to limit our use, disclosure, or both; and (c) to whom you want the limits to apply. You have the right to electronic copies of your protected health information when requested. Where information is not readily producible in the form and format requested, the information must be provided in an alternative readable electronic format as agreed to by you and we may charge a reasonable cost based fee for labor in copying protected health information and postage where you request that information be transmitted via mail or courier. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. For example, you may ask us to contact you by mail, rather than by phone at home. You do not have to provide us a reason for this request. We will accommodate reasonable requests. We also may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Please make this request in writing to our HIPAA Privacy and Security Officer. You may have the right to have us amend your protected health information. This means you may request an amendment of protected health information about you that we maintain. In certain cases, we may deny your request for an amendment. 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 HIPAA Privacy and Security Officer if you have questions about amending your health record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies generally to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. However, you do have the right to an accounting of disclosures for treatment, payment or health care operations if the disclosures were made from an electronic health record. Your right to an accounting of disclosures excludes disclosures we may have made to you, or to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding other disclosures that occurred up to six years from the date of your request (three years in the case of disclosures from an electronic health record made for treatment, payment or health care operations). You may request a shorter timeframe. The first list you request within a 12-month period is free of charge, but there is a charge involved with any additional lists within the same 12-month period. We will inform you of any costs involved with additional requests, and you may withdraw your request before you incur any costs. You have the right to obtain a paper copy of this Notice from us. You have the right to opt out of fundraising communications (if we conduct fundraising). You have the right to receive notice in the event of a breach of unsecured protected health information. This means that you will receive notice if a breach of your protected health information is discovered within 60 days of discovery. 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 us. You may file a complaint with us by notifying our HIPAA Privacy and Security Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our HIPAA Privacy Officer for further information about the complaint process. 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