The Retina Center at Las Vegas

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, please contact our Receptionist at our office at (702) 737-7258.

This notice describes information about privacy practices followed by our employees, staff and other office personnel. The practices described in this notice will also be followed by healthcare providers you consult with by telephone (when The Retina Center At Las Vegas is not available) who provide "call coverage" for The Retina Center At Las Vegas.

This notice applies to the information and records we have about your health, health status, and the healthcare and services you receive at this office. We are required by law to give you this notice. It will explain the ways in which we may use and disclose health information about you and describes your rights, and our obligations regarding the use and disclosure of that information.

For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.

A different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering X-ray procedures. Family members and other healthcare providers may be part of your medical care outside this office and may require information about you the we may have.

For Payment. We may use and disclose health information about you so the treatment and services you receive at The Retina Center At Las Vegas may be billed to and payment may be collected from you, an insurance company or a third party. We may disclose information regarding your treatment to your insurance company to determine whether your plan will cover the treatment; obtain prior approval/authorization for treatment, to receive reimbursement/payment for treatment.

For Healthcare Operations. We may use and disclose health information about you in order to run the office and make sure that you and other patients receive quality care. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain treatments are effective.

Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at our office.

Treatment Alternatives. We may advise you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services. We may tell you about Health-Related products or services that may be of interest to you.

Please notify us in writing (at The Retina Center At Las Vegas, 6839 W. Charleston Blvd. Las Vegas, NV 89117) if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. Your written request will be in effective when we receive it, but it will not apply to any uses and disclosures that occurred before that date and time.

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

To Avert a Serious Threat to Health or Safety. We may use and disclose 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.

Public Health Risks. We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abused or neglect, non accidental physical injuries, reactions to medications or problems with products.

Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate such donation and transplantation.

Research. We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your authorization/permission if the researcher will have access to your name, address, or other information that can uniquely identify you, or will be involved in your care at this office.

Workers' Compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

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

Military. Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

Law Enforcement. We may release health information f asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death.

Family and Friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you the opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person's involvement in your care.

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we can not take back any uses or disclosures already made with your permission.

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to The Retina Center at Las Vegas in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying (not to exceed $.60 per page copied), mailing or other associated supplies. We may deny your request to inspect and/or copy your health information, in certain limited circumstances.

Right to Amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. . You will be notified, in writing, if we deny your request.

To request an amendment, complete and submit a Medical Record Amendment/Correction Form to:

The Retina Center At Las Vegas
Russell P. Jayne, M.D.
6839 W. Charleston Blvd.
Las Vegas, NV 89117

We may deny request for an amendment if it s not in writing or does not include a reason to support the request. You will be notified, in writing, if we deny your request. In addition, we may deny your request f you ask us to amend information that The Retina Center At Las Vegas (a) did not create, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the health information we keep; (c) is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of your medical information about you for purposes other than treatment, payment and healthcare operations. To obtain this list, you must submit your request in writing to, our Receptionist. It must state a time period, which may not be longer than six years and may not include dates prior to April 14, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend.

We are Not Required to Agree to Your Request. If we agree with your request, we will comply with your request unless the information is needed to provide you emergency treatment. If we disagree with your request, you will be notified, in writing by us.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and submit the Request for Restriction On Use/Disclosure of Medical Information and/or Confidential Communication to our Receptionist (at The Retina Center At Las Vegas, 6839 W Charleston Blvd. Las Vegas, NV 89117). We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will make available a summary of the current notice in this office with its effective date in the top right hand comer. You are entitled to a copy of the notice currently in effect.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Receptionist at