Wheeler Family Eye Care
NOTICE OF PRIVACY PRACTICES
Effective Date of Notice: (April 15th 2003)

Dr. Jane E. Wheeler, O.D.
46 W. Broad Street,
Cookeville, TN 38501
(931) 528-7765

THIS NOTICE DESCRIBES HOW OPTOMETRIC & MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW
CAREFULLY.

At Wheeler Family Eye Care we respect our legal obligation to keep health information that identifies your private. We are obligated by
law to give you notice of our Privacy Practices. This Notice describes how we protect your health information and what rights you have
regarding this information.

TREATMENT, PAYMENT & HEALTH CARE OPERATIONS
The most common reasons we use or disclose your health information is for treatment, payment or internal health care operations. By law,
we are not required to receive your permission for these purposes. Examples of how we use/disclose information for treatment purposes
are: setting up an appointment for you, testing & examining your eyes and vision; diagnosing the status of your vision and ocular health;
prescribing medications or other treatment such as lasers, surgery or rehabilitation; faxing information to fill prescriptions; showing you
low vision aids; referring you to another health care provider or clinic; or getting copies of your health information from another
professional that you may have seen before us. Examples of how we use/disclose your health information for payment purposes are: asking
you about your health and vision plans; asking about other sources of payment; verifying benefit enrollment and/or eligibility; preparing
and sending bills or claims (either on paper or electronically); and collecting unpaid amounts (either ourselves or through a collection
agency or attorney). ?Health care operations? mean those administrative functions that we perform in order to run our offices. Examples
of how we use/disclose your health information for health care operations are: financial or billing audits; internal quality assurance;
participation in insurance and managed care plans; defense of legal matters; business planning and outside storage of our records.

We routinely use your health information inside our offices for these purposes without any specific permission-it is not required bylaw. If
we need to disclose your health information outside our offices for these reasons, we usually will ask for your specific permission. We will
ask for specific written permission in the following situations: 1) marketing of products/services for which we may receive payment, 2)
inclusion in medical studies or scientific research.

USES & DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some situations, the law requires us to use or disclose your information without your specific permission. Not all of these situations will
apply to our offices or to you; some may never come up in our offices. Such uses or disclosures are:
· When State or Federal law mandates disclosure;
· For public health purposes to prevent the spread of contagious disease, serious threat to public health or safety; for public health
research or health care operations; and notices to/from the federal Food & Drug Administration regarding medication or medical
devices;
· Disclosures regarding suspected victims of abuse, neglect or domestic violence;
· Disclosures for regulatory oversight by licensing boards, Medicare / Medicaid audits; or for investigation of possible health care
fraud;
· Disclosures for judicial and administrative proceedings (i.e. subpoenas or court orders);
· Disclosures for law enforcement purposes; to provide information about a crime; or to report a crime;
· Disclosure to a medical examiner; funeral directors or organizations that handle organ/tissue donations
· Uses/disclosures for health related research;
· Uses/disclosures relating to worker?s compensation programs;
· Incidental disclosures that are an unavoidable by-product of permitted use/disclosure;
· Disclosures to ?business associates? who perform health care operations for us and who commit to respect the privacy or your health
care information;

Unless you object, we will also share relevant information about your care with your immediate family or other caregivers (i.e. friends,
legal representatives) who are helping you with your eye health care.

APPOINTMENT REMINDERS
We may call/write to remind you of scheduled appointments or to notify you when you have missed an appointment or that it is time to
make an appointment for continuing care. If you refuse to allow us to contact you in such a manner, it may become necessary for us to
recommend you seek care from another provider, especially if we feel your refusal jeopardizes your health and/or vision. While we respect
your right to privacy, we insist that you become actively involved in your heath care and cooperate with us in providing such care. We
may also call/write to notify you of new/different treatments or services available for your vision and eye health condition.

OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written Authorization Form. Federal law
determines the content of an Authorization Form. We may, from time to time, initiate the ?authorization process? if use or disclosure is our
idea. Sometime, you may initiate the process if it is your idea for us to send your information to someone else. In this situation, you will
give us written instructions and authorization or you can use one of our standard forms.
I we initiate the process and ask you to complete an Authorization Form, you do not have to sign the authorization, we cannot make the
use or disclosure. If you do sign an Authofrization Form, you may revoke it at any time (in writing) unless we have already acted in
reliance upon the original authorization. Send revocations to the attention of the individual named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your personally identifiable health information. You can:
· Ask us to restrict our use/disclosure for purposes of treatment(except emergencies), payment or health care operations. We do not
have to agree to do this, but if we agree, we must honor the restrictions you describe. To ask for restrictions, send a written request to
the individual named on the front of this Notice.
· Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health
information to a different address. We will make every attempt to accommodate these requests if they are reasonable, and if you
agree to pay us for any extra costs. If you want to ask for confidential communications, send a written request to the individual
named on the front of this Notice.
· Ask to see or get photocopies of your health information. By law, these are a few limited situations in which we can refuse to permit
access or copying. For the most part, however, you will be able to review/copy your health information within 30 days of written
notice (60 days if the information is stores off-site). You may have to pay for photocopies in advance. If we deny your request we
will send you a written explanation and instructions about impartial review of our decision if legally available. By law, we may
have one 30-day extension of the time for us to give you access or photocopies if we send you written notice of the needed
extension. If you want to review or get copies of your health information, send a written request to the individual named at the front
of this Notice.
· Ask us to amend your health information if you think that it is incorrect or incomplete. We are not required to agree with your
request. If we agree, we will ament the information within 60 days of the written request. we will send the corrected information to
persons who we know for the wrong information and others that you specity. If we do not agree, you can write a statement of your
position and we will include it with your health information along with any rebuttal statement that we feel necessary. We will not
amend health information falsely. By law, we can have one 30-day extension of time to consider a request for amendment if we
notify you in writing of the extension. If you want to ask us to amend your information, send a written request to the individual
named in the front of this Notice.
· Get a list of the disclosures we have made of your health information that fall outside the parameters outlined in this notice. You
may request this information for any period up to and including six years from you last visit with us. By law, the list will not include:
disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures;
and disclosures required by law (for a complete listing see sections entitled Uses & Disclosures For Other Reasons Without
Permission, Appointment Reminders, and Other Uses & Disclosures). You are entitled to one such list per year without charge. If
you want more frequent lists, if applicable, you will have to pay for them in advance. We will usually respond to your request
within 60 days of receiving written notice. By law, we can have one 30-day extension of time if we notify you of the extension in
writing. If you want a list, send a written request to the individual named in the front of this Notice.
· Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or
in paper previously. If you want additional copies, send a written request to the individual named in he front of this Notice.

OUR NOTICE OF PRIVACY PRACTICES
We must abide by the terms of this Notice until we choose to make changes. We reserve the right to change this Notice at any time, as
allowed by law. If we change the Notice, the new privacy policies will apply to your health information that we already have on file as
well as to such information as we may create in the future. If we change our Notice or Privacy Practices, we will post the new Notice in
our offices, have copies available in our offices, and post the Notice on our web site. We, at Wheeler Family Eye Care, are committed to
the privacy of your health information and have established corporate policies (in addition to those outlined in this Notice) that guide the
training of our providers and staff members in our Privacy Practices. Further, we make every endeavor to assure that our business
associates are aware of our Privacy Practices and agree (whenever possible or required by law) to abide by these practices.

CONCERNS
If you think we may not have properly respected the privacy of your health information, you have the right to complain to us or to the U.S
. Department of Health and Human Services, Office for Civil Rights. We encourage you to notify us if you have a concern or complaint.
We will make every attempt to investigate all legitimate reports. We will not retaliate against you if you make a complaint. If you want
to register a concern or complaint, send a written statement or call the individual named on the front of this Notice.

FOR MORE INFORMATION
If you would like more information about our Privacy Practices, feel free to call or write number or address listed on the front of this
Notice.