Privacy Practices*Iowa Eye Prosthetics*Board Certified Ocularist*Plastic Artificial Eye*Human* 

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Procedure for Scleral Shell Prosthesis

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Privacy Practices



Vaune M. Bulgarelli


David M. Bulgarelli


Susan Hartman


    Privacy Practices 


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Notice Regarding Compliance with HIPAA

Please review this carefully before signing.

 This notice, which is required by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), informs you about our privacy practices. HIPAA 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. HIPAA provides penalties for covered entities that misuse personal health information.

We are required by law to maintain privacy of your health information and give you this Notice concerning this practice. We will keep your health information confidential, and with signing this Notice, your health information will only be used for the following purposes:

 Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you now or in the future.

 Payment: We may use and disclose your health information for reimbursement of services we provide to you.

 Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, conducting training programs, accreditation, or certification.

Appointment Reminders: We may use or disclose your health information to provide appointment reminders or other health-related benefits and services, including, but not limited to, voicemail messages, letters, postcards, FAX or email.

 Our Laboratory: Our laboratory is an open atmosphere. You will be able to visually see staff and other patients and conversations may be over-heard. No personal or health- related information will be disclosed to other patients without prior approval. We may ask you to speak with other patients (like children who are unsure), but you are not obligated to do so if it makes you uncomfortable. We are also educators in ocularistry and may have observers.

Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you or for consultation. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care if you agree to it. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

 Our Legal Duty: We reserve the right to change our privacy practices concerning all health information we maintain provided such changes are applicable by law. If any changes are made, we will change this Notice and make a new Notice available upon request. You may request a copy of our Notice at any time.

We may, without prior consent, use or disclose protected health information to carry out treatment, payment or health care operations in the following circumstances:

 Emergencies: If you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your case. This includes contacting someone responsible for your care or health-related information or supplies (example Rx) unless you have advised us otherwise.

 Legally: We may disclose your health information when we are required to do so by law or lawful process. We may also disclose information if requested by State or Federal officials.

 Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes to prevent a serious threat to your health or safety or that of others.

 You have the following rights with respect to your protected health information, which you can exercise by presenting a written request:

 Restrictions: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family, friends or any other person identified by you. We are 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.

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

 Other: You have the right to amend your protected health information. You have the right to receive an accounting disclosure of your health information. You have the right to obtain a paper copy of this notice upon request. You have the right to file a formal complaint.


Paper Copy: You have the right to request a paper copy of this notice from the front desk or request a copy be sent to you. This notice can also be downloaded from our website.(privacy-practices)


How to Contact Us:

Iowa Eye Prosthetics, Inc.

625 1st Avenue

Suite #200

Coralville, IA 52241


319-354-3465 FAX



I acknowledge that I have received a copy of Iowa Eye Prosthetics, Inc.'s

Notice of Privacy Practices.

PATIENTS PRINTED NAME                               

PATIENTS SIGNATURE                                      




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