Effective date of notice April 1, 2003

NOTICE OF PRIVACY PRACTICES

OPTIK BOUTIQUE Rhonda V. Dameron, O.D. 456 Fulton Street Suite 140 Peoria, Illinois 61602 Office (309) 674-6633

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.

The Health Insurance Portability & Accountability Act of 1996 (‘HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you, testing or examining your eyes; prescribing glasses, contact lenses or eye medications and faxing them to be filled; referring you to another doctor or clinic for eye care or services. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans or other sources of payment; preparing and sending bills or claims; and collection of unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning and outside storage of our records.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Some examples of such uses or disclosures include but are not limited to:

When a state or federal law mandates that certain health information be reported for a specific purpose

For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices

Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies

Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information

Unless you object, we will also share relevant information about your care with you family or friends who are helping you with your eye care.

OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of our health information unless you sign a written “authorization form.” Federal law determines the content of an “authorization form”. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: Dr. R. V. Dameron

The right to request restrictions on certain uses and disclosures of protected health information including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

The right to inspect and copy your protected health information.

The right to receive an accounting of disclosures of protected health information.

The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms or our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information: For more information about HIPPA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 (202) 619-0257 Toll Free: 1-877-696-6775