16427 N Scottsdale Rd Suite 105
Scottsdale, AZ 85254
1245 W. Chandler Blvd Suite #3
Chandler, AZ 85224
1951 S.W. 172 Avenue, Suite 304 (located in Memorial Hospital Miramar)
Miramar, FL 33029
8705 Perimeter Park Blvd Suite 10
Jacksonville, FL 32216
155 Cranes Roost Blvd Suite 1060
Altamonte Springs, FL 32701
2202 North West Shore Blvd Suite 100
Tampa, FL 33607
200 Galleria Parkway Suite 200
Atlanta, GA 30339
3175 Satellite Blvd Building 600, Suite 175
Duluth, GA 30096
939 W North Ave Suite 220
Chicago, IL 60642
3021 Butterfield Rd Suite 200
Oak Brook, IL 60523
999 Plaza Dr Suite 100
Schaumburg, IL 60173
2348 Nicholasville Rd. Suite 140
Lexington, KY 40503
3999 Dutchman's Lane, Suite 5F (located in Norton St. Matthews Medical Building, Plaza 1)
Louisville, KY 40207
22 West Road Suite 201
Towson, MD 21204
10025 Governor Warfield Parkway Suite 103
Columbia, MD 21044
800 King Farm Blvd Suite 135
Rockville, MD 20850
42000 Six Mile Road, Suite 200 (located in Adelson Eye & Laser Center)
Northville, MI 48168
12745 23 Mile Road Suite #100
Shelby , MI 48315
3300 Edinborough Way Suite 412
Edina, MN 55435
7767 Elm Creek Blvd Suite 140
Maple Grove, MN 55369
8344 3rd Street North
Oakdale, MN 55128
102 James Street Suite 204
Edison, NJ 08820
351 Evelyn Street Suite 301
Paramus, NJ 07652
303 Fellowship Rd Suite 100
Mt. Laurel, NJ 08054
12 Corporate Woods Blvd
Albany, NY 12211
14 Hope Street Suite 2
Brooklyn, NY 11211
7840 Montgomery Rd Suite 100, First Floor
Cincinnati, OH 45236
6800 Rockside Rd Unit A
Cleveland, OH 44131
4030 Easton Station Suite 220
Columbus, OH 43219
6470 Centerville Business Parkway
Dayton, OH 45459
13321 N Meridian Ave, Suite 110 located in Sylvester Eye Care
Oklahoma City, OK 73120
4640 High Pointe Blvd Suite 60
Harrisburg, PA 17111
216 Mall Blvd Suite 100
King of Prussia, PA 19406
5000 McKnight Rd
Pittsburgh, PA 15237
3410 Far West Blvd. Suite 150
Austin, TX 78731
2108 Dallas Parkway Suite 206
Dallas, TX 75093
3700 Buffalo Speedway Suite 325
Houston, TX 77098
7720 Jones Maltsberger Suite 101
San Antonio, TX 78216
10571 Telegraph Rd Suite 100
Glen Allen, VA 23059
1101 King Street Suite 100
Alexandria, VA 22314
8280 Greensboro Dr Suite 110
McLean, VA 22102
1300 SW 7th St. Suite 105
Renton, WA 98057
2204 E. 29th Avenue Suite 110
Spokane, WA 99203
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.
OUR COMMITMENT TO YOUR PRIVACY
Our facility is required by law to maintain the privacy of your identifiable Protected Health Information and to provide
individuals with notice of our legal duties and privacy practices with respect to such information.
This Notice will provide you with information regarding our privacy practices and applies to all Protected Health
Information created and/or maintained by the facility, including any information that we receive from other health care
providers. The Notice describes the ways in which the facility may use or disclose your Protected Health Information and
also describes your rights and our obligations regarding any such uses or disclosures. The facility will abide by the terms
of this Notice, including any future revisions that we may make to the Notice as required or authorized by law.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
The following describes the ways we may use and disclose health information that identifies you (“Protected Health
Information”). Except for the purposes described below, we will use and disclose Protected Health Information only with
your written permission. You may revoke such permission at any time by writing to our facility Privacy Officer.
For Treatment. We may use and disclose Protected Health Information for your treatment and to provide you with
treatment-related health care services. For example, we may disclose Protected Health Information to doctors, nurses,
technicians, or other personnel, including people outside our office (for example, your pharmacy) who are involved in
your medical care and need the information to provide you with medical care.
For Payment. We may use and disclose Protected Health Information so that we or others may bill and receive payment
from you, an insurance company or a third party for the treatment and services you received. For example, we may give
your health plan information about you so that they will pay for your treatment.
For Health Care Operations. We may use and disclose Protected Health Information for health care operations
purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to
operate and manage our facility. For example, health care operations may include quality improvement activities and
business management and administrative activities. We also may share information with other entities that have a
relationship with you (for example, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose
Protected Health Information to contact you to remind you that you have an appointment with us. We also may use and
disclose Protected Health Information to tell you about treatment alternatives or health-related benefits and services
that may be of interest to you.
Research. Under certain circumstances, we may use and disclose Protected Health Information for research purposes.
For example, we may disclose your information to researchers preparing to conduct an investigation to help
them look for patients with specific medical conditions.
USES OR DISCLOSURES PERMITTED BY LAW IN SPECIAL SITUTATIONS
As Required by Law. We will disclose Protected Health Information when required to do so by international, federal,
state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information when necessary
to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Business Associates. We may disclose Protected Health Information to our business associates that perform functions
on our behalf or provide us with services if the information is necessary for such functions or services. For example, we
may use another company to perform billing services on our behalf. All of our business associates are obligated to
protect the privacy of your information and are not allowed to use or disclose any information other than as specified in
our contract with the business associate.
Military and Veterans. If you are a member of the military, we may release Protected Health Information as required by
military command authorities.
Workers’ Compensation. We may release Protected Health Information for workers’ compensation or similar programs
which provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Protected Health Information for public health activities. For example, we may
disclose information to prevent or control disease, injury or disability or to notify you of a recall of a product you may be
Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and
certification surveys. These activities are necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally
required notices of unauthorized access to or disclosure of your Protected Health Information.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in
response to a court or administrative order. We also may disclose Protected Health Information in response to a
subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have
been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release Protected Health Information if asked by a law enforcement official if the information
is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or
locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very
limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result
of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location
of the crime or victims, or the identity, description or location of the person who committed the crime.
National Security and Intelligence Activities. We may release Protected Health Information to authorized federal
officials for intelligence, counter-intelligence, and other national security activities authorized by law.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release Protected Health Information to the correctional institution or law enforcement
official if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the
health and safety of others; or (3) for the safety and security of the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO AGREE OR OBJECT
Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your
family, a relative, a close personal friend or any other person you identify, your Protected Health Information that directly
relates to that person’s involvement in your health care or payment. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our
Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your
Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a
disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be
made only with your written authorization. If you do give us an authorization, you may revoke it at any time by
submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under
the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be
affected by the revocation.
You have the following rights regarding Protected Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Protected Health Information that may be used to make
decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy
notes. To inspect and copy this Protected Health Information, you must make your request, in writing, to the facility’s
Privacy Officer. We have up to 30 days to make your Protected Health Information available to you and we may charge
you a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an
electronic format, you have the right to request that an electronic copy of your record be given to you or
transmitted to another individual or entity. We will provide access to your Protected Health Information in the
form or format you request, if it is readily producible in such form or format. If the Protected Health Information
is not readily producible in the form or format you request your record will be provided in either our standard
electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a
reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected
Right to Request an Amendment. If you feel that Protected Health Information we have is incorrect or incomplete, you
may ask us to amend the information. You have the right to request an amendment for as long as the information is kept
by or for our facility. To request an amendment, you must make your request, in writing, to the facility’s Privacy Officer.
In addition, you must provide us with a reason that supports your request. In certain cases, we may deny your
request for amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with the decision and we may give a rebuttal to your statement.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Protected
Health Information for purposes other than treatment, payment and health care operations or for which you provided
written authorization. To request an accounting of disclosures, you must make your request, in writing, to the Privacy
Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health
Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a
limit on the Protected Health Information we disclose to someone involved in your care or the payment for your care,
such as a family member or friend. For example, you could ask that we not share information about a particular
diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Privacy
Officer. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your
Protected Health Information to a health plan for payment or health care operation purposes and such information you
wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we
agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health
plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to
that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will
honor that request.
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 by mail or at
work. To request confidential communications, you must make your request, in writing, to the Privacy Officer. Your
request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a
copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a
paper copy of this Notice. You may obtain a copy of this Notice at our web site, www.lasikplus.com. To obtain a paper
copy of this Notice please contact the Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice and make the new Notice apply to Protected Health Information we already
have as well as any information we receive in the future. We will post a copy of our current Notice at our facilities and on
our website. The Notice will contain the effective date on the last page.
If you have any questions about this Notice or if you believe we have not properly protected your privacy, or
have violated your privacy rights, you may contact our Privacy Officer. You also may send a written complaint
to the U.S. Department of Health and Human Services. The Privacy Officer can provide you with the
appropriate address upon request. There will not be retaliation against those who choose to file a complaint.
To act on any of the information provided in this Notice or for more information about our privacy practices, you
may contact our Privacy Officer at:
Mail: 7840 Montgomery Road, Cincinnati, OH 45236
Effective Date: December 1, 2017
Life-changing results from real LasikPlus patients.