This is a copy of the HIPAA document that you will receive and sign as a patient in our office.

Notice of Privacy Practices:  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 Privacy Heritage Optical, is committed to maintaining the privacy of your protected health information.  This Notice of Privacy Policies describes how we use and disclose your health information and your rights regarding it.  This notice is effective January 14, 2009, and applies to all protected health information as defined by federal regulations.

Understanding Your Health Record

Each time you visit our practice; a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.  This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, Tool in educating health professionals, Source of data for medical research, Source of information for public health officials charged to improve the health of the state and nation, Source of data for our planning and marketing, Tool by which we can assess and continually work to improve the care we render and outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to: Ensure its accuracy; better understand who, what, when, where, and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of our practice, the information belongs to you.  You have the right to:

-Obtain a paper copy of this notice of privacy practices upon request
-Inspect and copy your health record
-Obtain an accounting of disclosures of your health information
-Request confidential communications of your health information
-Request a restriction on certain uses and disclosures of your information
-Amend your health record

Our Responsibilities. Our Practice is required to: Maintain the privacy of your health information. Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you:

Abide by the terms of this notice. Notify you if we are unable to agree to a requested restriction. Accommodate reasonable requests you may have to communicate your health information. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.  We will keep a posted copy of the most current notice in our facility containing the effective date.  In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon the request. We will not sue or disclose your health information in a manner other than permitted by HIPPA and Michigan State law, without your written authorization, which you may revoke, except to the extent that action has already been taken.

Notice of Financial Consent

Consent to Release Medical Records and Information to My Insurance Company: I authorize Heritage Optical Center, Inc. to release information from my medical records to any person, organization, employer (if work-related injury), or review agency, which is legally or contractually responsible for payment of my bills for services.  I further authorize Heritage Optical Center, Inc. to release information from my medical records to auditors and consultants who are advising Heritage Optical Center, Inc. on third party payor billing issues and/or assisting Heritage Optical Center, Inc.  in preparing financial data and related documents.  I understand that Heritage Optical Center, Inc. will maintain the confidentiality of my medical records, but I further understand that Heritage Optical Center, Inc. is not responsible for any breaches of confidentiality of my medical records caused by other parties.  This permission includes information that may be related to drug or alcohol abuse, psychiatric care, HIV testing, AIDS (Acquired Immunodeficiency Syndrome), HIV infection or ARC (AIDS related complex).

Consent to Disclose Information to Individuals Involved in My Care or Payment for My Care: I authorize Heritage Optical Center, Inc. and its employees to release information from my financial or medical records to a person, organization, employer (IF work-related injury), or review agency which is responsible, or which Heritage Optical Center, Inc. reasonably thinks may be responsible, for the payment of my bills for my medical care.

Financial Agreement: I understand that Heritage Optical Center, Inc. submits claims to insurance carriers as a courtesy to patients and that I am responsible for the balance owed unless Heritage Optical Center, Inc. has agreed with the payor not to balance bill.  I agree to pay for all services rendered to me without regard to any benefit limitations imposed by any third-party payor, unless other arrangements are made in advance, to pay my account in full upon completion of services rendered by Heritage Optical Center, Inc.; to pay any legal fees and interest at the legal rate which result due to my not paying my balance.  I understand Heritage Optical Center, Inc. accepts no liability for failure to meet any pre-cost certification required by my insurance carrier, and I agree that such certification has been or will be properly executed by me.

Assignment of Benefits: I hereby assign to Heritage Optical Center, Inc. all of my insurance and managed care benefits due to me for services rendered to me by Heritage Optical Center, Inc.  I authorize my insurance company and/or my managed care company to make payment directly to Heritage Optical Center, Inc. If you have any questions or concerns about this notice or you want to submit a written request, please use contact information above.

For More Information or to Report a Problem For any concerns or questions about this notice contact the Privacy Officer at:

Heritage Optical Center, Inc.     Attn: Privacy Officer
19010 Livernois Avenue, Detroit, Michigan 48221

Office 313-863-9585      Facsimile 313-863-7710      corporate@heritageoptical.com