Effective April  14. 2003

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.

If you have any questions about this notice, please contact our Privacy Office.

This notice describes the privacy practices of all employees, physicians, and healthcare providers of our Clinic. The privacy practices information in this notice will be followed by all departments and units of our organization who share information as permitted within our organized health care arrangement and any business associate or partner with whom we share health information.

We understand that medical and billing information about you is personal. We are committed to protecting the privacy of your medical and billing information.  We are required by law maintain the privacy of your medical and billing information.  We create a record of the care and services you receive. We need this record to provide you with quality care to comply with certain legal requirements. We are required to give you this Notice of our legal duties and privacy practices with respect to your protected health information.  If we revise this Notice, we will follow the terms of the revised Notice as long as it is currently in effect.

We may use or disclose medical and billing information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out protected health information about you without prior authorization to insure proper payment of claims submitted. We may also disclose protected health information when required by law, such as in response to a request from law enforcement officials in specific circumstances, or in response to valid judicial or administrative orders.

In any other situation is not covered by this Notice, we will ask for your written authorization before using or disclosing your protected health information. If you choose to authorize our use or disclose of your protected health information, you can later revoke that authorization by notifying us in writing of your decision.

You have the right to a list of those instances where we have disclosed medical and billing information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure. When you submit a written request, the request must state the time period desired for the accounting, which must be less that a six year period and starting after April 14, 2003. You may receive the list in paper form. This first disclosure list request in a 12 month period will be provided to you at no cost; other requests will be charged in accordance with our cost to produce the list. We will inform you of the cost before you incur any charges.

You have the right to request that your medical and billing information be communicated to you in a confidential manner such as sending mail to an address other than your home. You must notify us in writing of the specific way or location for us to use to communicate with you.

You may request, in writing, that we not use or disclose protected health information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, or when required by law, or in an emergency.  We will consider your request but we are not legally required to accept it. We will inform you of our decision.

You have the right to amend. in writing, if you feel that medical information we have about you is incorrect or incomplete. All written requests or appeals should be submitted to our Privacy Office listed on this Notice.

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office.

Finally you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office will provide you the address upon request.

Under no circumstance will you be penalized or retaliated against for filing a complaint.

Texarkana Vision Group, PLLC

Fowler Eye Care

4224 Texas Blvd

Texarkana, TX 75503

903-794-3711

Ashdown Eye Care

102 Southern Dr Ste 4

Ashdown, AR 71822

870-898-7700