Oklahoma Eye Institute Privacy Notice

If you have any questions about this notice, please contact Oklahoma Eye Institute. This notice describes
the health and medical information policies and procedures of Oklahoma Eye Institute. It applies to all
staff, employees, independent contractors and business associates of Oklahoma Eye Institute.

• Our Pledge Regarding Medical Information
  We understand the importance of privacy and are committed to maintaining the confidentiality of your
  medical information. We make a record of the medical care we provide and may receive such records
  from others. We use these records to provide or enable other health care providers to provide quality
  medical care, to obtain payment for services provided to you as allowed by your health plan and to
  enable us to meet our professional and legal obligations to operate this medical practice properly. We
  are required by law to maintain the privacy of protected health information, to provide individuals with
  notice of our legal duties and privacy practices with respect to protected health information, and to
  notify affected individuals following a breach of unsecured protected health information. This notice
  describes how we may use and disclose your medical information. It also describes your rights and our
  legal obligations with respect to your medical information.
• How We May Use and Disclose Your Medical Information
  Oklahoma Eye Institute collects health information about you and stores it in a chart, and on a
  computer, and in an electronic health record/personal health record. This is your medical record. The
  medical record is the property of this medical practice, but the information in the medical record
  belongs to you. The law permits us to use or disclose your health information for the following
  purposes:

For treatment:

Oklahoma Eye Institute may use medical information about you to provide you with medical
treatment and services. We may disclose medical information about you to doctors, nurses,
technicians, medical students, or other personnel who are involved in taking care of you.
Oklahoma Eye Institute may share medical information about you in order to coordinate the
different things you need, such as prescriptions, lab work and/or x-rays.

For Payment:

We may use and disclose medical information about you so that treatment and services you
receive may be billed to and payment collected from you, an insurance company or a
third-party. We may also share your health plan information about a treatment you are going to
receive to obtain prior approval or to determine whether your plan will cover treatment.

Health Care Operations:
We may use and disclose medical information about you to operate this medical practice. For
example, we may use and disclose this information to review and improve the quality of care we
provide, or the competence and qualifications of our professional staff. Or we may also use and
disclose this information to get your health plan to authorize services or referrals. We may also
use and disclose this information as necessary for medical reviews, legal services and audits,
including fraud and abuse detection and compliance programs and business planning and
management. We may also share your medical information with our "business associates," such
as our billing service, that perform administrative services for us. We have a written contract
with each of these business associates that contains terms requiring them and their
subcontractors to protect the confidentiality and security of your protected health information.
We may also share your information with other health care providers or health plans that have a
relationship with you, when they request this information to help them with their quality
assessment and improvement activities, their patient-safety activities, their population-based
efforts to improve health or reduce health care costs, their protocol development, case
management or care-coordination activities, their review of competence, qualifications and
performance of health care professionals, their training programs, their accreditation,
certification or licensing activities, or their health care fraud and abuse detection compliance
efforts.

Appointment Reminders:
We may use and disclose medical information to contact you as a reminder that you have an
appointment for treatment or medical care. If you are not home, we may leave this information
on your answering machine or in a message left with the person answering the phone. This
practice does not sell, rent, or lease its customer lists or mobile data to third parties for
marketing purposes.

Sign In Sheet:
We may use and disclose medical information about you by having you sign in when you arrive
at our office. We may also call out your name when we are ready to see you.

Treatment Alternatives:
We may use and disclose medical information to tell you about or recommend possible
treatment options or alternatives that may be of interest to you.

Health Related Benefits and Services:
We may use and disclose medical information to tell you about health-related benefits or
services that may be of interest to you.

Notification and Communications with Family:
We may disclose your health information to notify or assist in notifying a family member, your
personal representative or another person responsible for your care about your location, or
your general condition unless you have instructed us otherwise. In the event of a disaster, we
may disclose information to a relief organization so that they may coordinate these notification
efforts. We may also disclose information to someone who is involved with your care or helps
pay for your care. If you are able and available to agree or object, we will give you the
opportunity to object prior to making these disclosures. If you are unable or unavailable to
agree or object, our health professionals will use their best judgment in communication with
your family and others.

Research:
Under certain circumstances, we may use and disclose medical information about you for
research purposes. Before we use or disclose medical information about you to people
preparing to conduct a research project, the project will have been approved through a research
approval process. We may, however, disclose your medical information to people preparing to
conduct a research project to help them look for patients with specific medical needs. We will
ask for your specific permission if the researcher will have access to your name, address or other
information that reveals who you are, or will be involved in your care through Oklahoma Eye
Institute.

Marketing:
Provided we do not receive any payment for making these communications, we may contract
you to give you information about products or services related to your treatment, case
management or care coordination, or to direct or recommend other treatments, therapies,
health care providers or settings of care that may be of interest to you. We may describe similar
products or services provided by this practice and tell you which health plans this practice
participates in. We will not otherwise use or disclose your medical information for marketing
purposes or accept any payment for other marketing communications without your prior
written authorization. The authorization will disclose whether we receive any compensation for
any marketing activity you authorize, and we will stop any future marketing activity to the
extent you revoke that authorization.

Sale of Health Information:
We will not sell your health information without your prior written authorization. The
authorization will disclose that we will receive compensation for your health information if you
authorize us to sell it, and we will stop any future sales of your information to the extent that
you revoke that authorization.

As Required by Law:
As required by law, we will use and disclose your health information, but we will limit our use or
disclosure to the relevant requirements by the law. When the law requires us to report abuse,
neglect or domestic violence, or respond to judicial or administrative proceedings, or to law
enforcement officials, we will further comply with the requirement set forth below concerning
those activities.

To Avert A Serious Threat to Health or Safety:
We may use and disclose medical information about you when necessary to prevent a serious
threat to your health and to the safety of the public or another person. Any disclosure, however,
would only be to help prevent the threat.

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

Military and Veterans:
If you are a member of the armed forces, we may release medical information about you as
required by military command authorities. We may also release medical information to foreign
military authorities.

Workers' Compensation:
We may disclose your health information as necessary to comply with workers' compensation
laws. We are also required by law to report cases of occupational injury or occupational illness
to the employer or workers' compensation insurer. The release of such information is controlled
by the state and /or federal law.

Public Health Risks:
We may, and are sometimes required by law, to disclose your health information to public
health authorities for purposes related to preventing or controlling disease, injury or disability;
reporting child, elder or dependent adult abuse or neglect; reporting domestic violence;
reporting to the Food and Drug Administration problems with products and reactions to
medications; and reporting disease or infection exposure. When we report suspected elder or
dependent adult abuse or domestic violence, we will inform you or your personal representative
promptly unless in our best professional judgment, we believe the notification would place you
at risk of serious harm or would require informing a personal representative we believe is
responsible for the abuse or harm.

Health Oversight Activities:
We may disclose medical information to a health oversight agency for activities authorized by
law. These oversight activities include, for example, audits, investigations, inspections and
licensure. These activities are necessary for the government to monitor the healthcare system,
government programs, and compliance with civil rights law.

Change of Ownership:
In the event that this medical practice is sold or merged with another organization, your health
information/record will become the property of the new owner, although you will maintain the
right to request that copies of your health information be transferred to another physician or
medical group.

Breach Notification:
In the case of a breach of unsecured protected health information, we will notify you as
required by law. If you have provided us with a current e-mail address, we may use e-mail to
communicate information related to the breach. In some circumstances our business associate
may provide the notification. We may also provide notification by other methods as
appropriate.

Lawsuits and Disputes:
If you are involved in a lawsuit or dispute, we may disclose medical information about you 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 to obtain an order
protecting the information requested.

Law Enforcement:
We may, and are required by law, to disclose your health information to a law enforcement
official for purposes such as identifying or locating a suspect, fugitive, material witness or
missing person, complying with a court order, warrant, grand jury subpoena and other law
enforcement purposes.

Specialized Government Functions:
We may disclose your health information for military or national security purposes or to
correctional institutions or law enforcement officers that have you in their lawful custody.

Inmates:
If you are an inmate of a correctional institution or under the custody of a law enforcement
official, we may release medical information about you to the correctional institution or law
enforcement official. This release would be necessary (1) for Oklahoma Eye Institute 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.

• When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal
obligations, not use or disclose health information which identifies you without your written
authorization. If you do authorize this medical practice to use or disclose your health information for
another purpose, you may revoke your authorization in writing at any time.

• Your Health Information Rights

Right to Request Special Privacy Protections:
You have the right to request restrictions on certain uses and disclosures for your health
information by a written request specifying what information you want to limit, and what
limitations on our use or disclosure of that information you wish to have imposed. If you tell us
not to disclose information to your commercial health plan concerning health care items or
services for which you paid for in full out-of-pocket, we will abide by your request, unless we
must disclose the information for treatment or legal reasons. We reserve the right to accept or
reject any other request and will notify you of our decision.

Right to Inspect and Copy:
You have the right to inspect and copy medical information that may be used to make decisions
about your care. To inspect and copy medical information that may be used to make decisions
about your care, you must submit your request to the office manager of Oklahoma Eye Institute.
If you request a copy of the information, we may charge a reasonable fee for the costs of
copying, mailing or other supplies associated with your request.

Right to Amend or Supplement:
You have the right to request that we amend your health information that you believe is
incorrect or incomplete. You must make a request to amend in writing and include the reasons
you believe the information is inaccurate or incomplete. We are not required to change your
health information and will provide you with information about this medical practice's denial
and how you can disagree with the denial. We may deny your request if we do not have the
information, if we did not create the information, if you would not be permitted to inspect or
copy the information at issue, or if the information is accurate and complete as it is. If we deny
your request, you may submit a written statement of your disagreement with that decision, and
we may, in turn, prepare a written rebuttal. All information related to any request to amend will
be maintained and disclosed in conjunction with any subsequent disclosure of the dispute
information.

Right to an Accounting of Disclosures:
You have the right to request an "accounting of the disclosures." This is a list of the disclosures
we made of medical information about you. To request this list or accounting of disclosures, you
must submit the request in writing to the office manager of Oklahoma Eye Institute. Your
request must state a time period which may be no longer than six years prior. Your request
should indicate in what form you want the list (for example, on paper or electronically). The first
list you request within a 12-month period will be free. For additional lists, we may charge you
for the cost 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 medical information we use or
disclose about you for treatment, payment or health-care operations. You also have the right to
request a limit on medical information we disclose about you to someone who is involved in
your care or the payment of your care, like a family member or friend. We are not required to
agree with your request. If we do agree, we will comply with your request unless the
information is needed to provide you with emergency treatment. To request a restriction, you
must make your request in writing to the office manager of Oklahoma Eye Institute. In your
requested restrictions, you must tell us (1) what information you want to limit; (2) whether you
want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications:
You have the right to request that you receive your health information in a specific way or at a
specific location. For example, you may ask that we send information to a particular e-mail
address or to your work address. We will comply with all reasonable requests submitted in
writing which specify how or where you wish to receive these communications.

Right to a Paper or Electronic Copy of this Notice:
You have a right to notice of our legal duties and privacy practices with respect to your health
information, including a right to a paper copy of this Notice of Privacy Practices, even if you have
previously requested its receipt by e-mail.

Changes to this Notice of Privacy Practices:
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until
such amendment is made, we are required by law to comply with the terms of this Notice
currently in effect. After an amendment is made, the revised Notice of Privacy Protections will
apply to all protected health information that we maintain, regardless of when it was created or
received. We will keep a copy of the current notice posted in our reception area, and a copy will
be available at each appointment. We will also post the current notice on our website.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with your office
or with the Secretary of the Department of Health and Human Services. To file a complaint with
Oklahoma Eye Institute, contact the office manager for Oklahoma Eye Institute at
1-800-886-1591. All complaints must be submitted in writing. You will not be penalized for filing
a complaint.