NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW KORNMEHL LASER EYE ASSOCIATES MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by Kornmehl Laser Eye Associates to carry out treatment, payment, or healthcare operations. You must request such a restriction in writing. We are not required to agree to your request, but if we do agree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare providers treating you. Also, a restriction would not apply when we are required by law to disclose certain healthcare information.

You have the right to review and/or obtain a copy of your healthcare records, with the exception of psychotherapy notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action proceeding. Kornmehl Laser Eye Associates may deny an access under other circumstances, in which case you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.

You may request that Kornmehl Laser Eye Associates send protected health information, including billing information, to you by alternative means or to alternative locations. You may also request that Kornmehl Laser Eye Associates not send information to a particular address or location or contact you at a specific location, perhaps your place of employment. This request must be submitted in writing. We will accommodate reasonable requests by you.

You have the right to request that Kornmehl Laser Eye Associates amend portions of your healthcare records, as long as such information is maintained by us. You must submit this request in writing, and under certain circumstances the request may be denied.

You may request to receive an accounting of the disclosures of your protected health information made by Kornmehl Laser Eye Associates for the six years prior to the date of the request, beginning with disclosures made after April 14, 2003. We are not required, however, to record disclosures we make pursuant to a signed consent or authorization.

You may request and receive a paper copy of this Notice, if you had previously received or agreed to receive the Notice electronically.

Any person or patient may file a complaint with Kornmehl Laser Eye Associates and/or the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with Kornmehl Laser Eye Associates, please contact the Privacy Officer at the following: Privacy Officer, Kornmehl Laser Eye Associates, 62 Walnut Street, Wellesley, MA 02481

It is the policy of Kornmehl Laser Eye Associates that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance or violation of privacy standards.

This Notice of Privacy Practices is effective April 14, 2003.

This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F. R. 164.520.

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Please choose one of the following options:

Please fill out the form above and mail to our address: Kornmehl Laser Eye Associates 44 Washington Street (Rt. 9) Brookline, MA 02445 Att: Privacy Officer 62 Walnut Street Wellesley, MA 02481

Please fill out the form above and click here to send your information to our practice over the web digitally.