Privacy Notice

NOTICE OF PRIVACY PRACTICES EFFECTIVE 04/01/03

Colchester Eye Care, LLC

163 Broadway Colchester, CT 06415
(860) 537-2020 Phone
(860) 537-2875 Fax

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.

GENERAL RULE We respect our legal obligation to keep health information that identifies you private. We are
obligated by law to give you notice of our privacy practices.

Generally, we cannot use your health information in our offices or disclose it outside of our office without your written
permission. Sometimes the written permission will be called a consent form, and sometimes it will be called an
authorization form. The type of permission form will depend upon the kinds of uses or disclosures that are involved. In
some limited situations, the law allows or requires us to disclose your health information without either a written consent
or authorization.

USES OR DISCLOSURES WITH CONSENT We will ask you to sign a consent form allowing us to use and disclose your
health information for purposes of treatment, payment, and health care operations of this office. We are allowed to
refuse to treat you if you do not sign.

We use information for treatment purposes, when, for example, we set up an appointment for you, when our technician
or doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when the doctor prescribes
medication, when our staff helps you select and order glasses and contact lenses, and when we show you low vision
aids. We may disclose your health information outside of our office for treatment purposes if, for example, we refer you
to another doctor or clinic, if we send a prescription for glasses or contacts to be filled, when we provide a prescription
for medication to a pharmacist, or when we phone to let you know that your glasses or contact lenses are ready to be
picked up. Sometimes we may ask for copies of your health information from another professional that you may have
seen before us.

We use you health information for payment purposes when, for example, our staff asks you about health or vision care
plans to which you may belong, or about other sources of payment for our services, when we prepare bills to send to
you or your health or vision care plan, when we process payment by credit card, and when we try to collect unpaid
amounts due. We may disclose your health information outside of our office for payment purposes when, for example,
bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan, or when we
occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.

Health care operations means those administrative and managerial functions that we have to perform in order to run
our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality
assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of
legal matters, to develop business plans, and for outside storage of our records.

USES AND DISCLOSURES WITHOUT CONSENT OR AUTHORIZATION In some limited situations, the law allows or
requires us to use or disclose your health information without your permission. Not all of these situations will apply to
us; some may never come up at our office at all. Such uses or disclosures are:

 when a state or federal law mandates that certain health information be reported for a specific purpose:  for public
health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Food
and Drug Administration regarding drugs or medical devices;  disclosures to governmental authorities about victims of
suspected abuse, neglect or domestic violence;  uses and disclosures for health oversight activities, such as for the
licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; 
disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or
administrative agencies;  disclosures for law enforcement purposes, such as to provide information about someone
who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime
that happened somewhere else;  disclosure to a medical examiner to identify a dead person or to determine the
cause of death; or to a funeral directors to aid in burial; or to organizations that handle organ or tissue donations; 
uses or disclosures for health related research;  uses and disclosures to prevent a serious threat to health or safety;
 uses or disclosures for specialized government functions, such as for the protection of the president or high ranking
government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of
members of the foreign service;  disclosures relating to worker's compensation programs;  disclosures to business
associates who perform health care operations for us and who agree to keep your health information private.

APPOINTMENT REMINDERS We may call to remind you of scheduled appointments. We may also call to notify you of
other treatments or services available at our office that might help you.

OTHER DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a
written authorization form. You do not have to sign such a form. If you do sign one, you may revoke it at any time
unless we have already acted in reliance upon it.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health
information. You can:

 ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or
health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you
want. To ask for a restriction, send a written request to Tracy L. Gale, our office manager, at the address or fax shown
at the beginning of the Notice.  ask us to communicate with you in a confidential way, such as by phoning you at work
rather than at home or by mailing health information to a different address. We will accommodate these requests if they
are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written
request to Tracy L. Gale, our office manager, at the address or fax shown at the beginning of the Notice.

 ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can
refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health
information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we
will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally
required. By law, we can have one 30-day extension of the time for us to give you photocopies if we send you written
notice of the extension. If you want to review or get photocopies of your health information, send a written request to
Tracy L. Gale, our office manager, at the address or fax shown at the beginning of the Notice.  ask us to amend your
health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days
from when you ask us. We will send the corrected information to persons who we know got the wrong information, and
others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your
health information along with any rebuttal statement that we may write. Once your statement of position and/or our
rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your
health information. By law, we can have one 30-day extension of time to consider a request for amendment with written
notification. If you want to ask us to amend your health information, send a written request to Tracy L. Gale, our office
manager, at the address or fax shown at the beginning of the Notice.  get a list of the disclosures that we have made
of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of
treatment, payment, or health care operations and some other limited disclosures. You are entitled to one such list per
year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond
to your request within 60 days of receiving it, but by law, we can have one 30-day extension of time if we notify you of
the extension in writing. If you want a list, send a written request to Tracy L. Gale, our office manager, at the address or
fax shown at the beginning of the Notice.  get additional paper copies of this Notice of Privacy Practices upon request,
no matter whether you received one already. If you want additional paper copies, send a written request to Tracy L.
Gale, our office manager, at the address or fax shown at the beginning of the Notice.

OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we
choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If
we change this Notice, the new privacy practices will apply to your health information that we already have as well as to
such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new
notice in our office and have copies available in our office.

COMPLAINTS If you think that we have not properly respected the privacy if your health information, you are free to
complain to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you
if you make a complaint. If you want to complain to us, send a written complaint to Tracy L. Gale, our office manager, at
the address or fax shown at the beginning of the Notice. If you prefer, you can discuss your complaint in person or by
phone.

FOR MORE INFORMATION If you want more information about our privacy practices, call or visit Tracy L. Gale, our
Office Manager, at the address or phone number shown at the beginning of this Notice.