NOTICE OF PRIVACY PRACTICES
Effective Date: 2021
Arvada Optometric Center
7913 Allison Way Ste. 102
Arvada, CO 80005
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
PLEASE REVIEW IT CAREFULLY
WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by our employees, staff and other
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about you, your health, health status, and the
health care and services you receive from Arvada Optometric Center. Your health information may include
information created and received by Arvada Optometric Center, may be in the form of written or electronic
records or spoken words, and may include information about your health history, health treatments,
procedures, prescriptions, related billing activity and similar types of health-related information. We are
required by law to give you this notice. It will tell you about the ways in which we may use and disclose
health information about you and describes your rights and our obligations regarding the use and disclosure
of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose health information for the following purposes:
• For Treatment. We may use health information about you to provide you with medical treatment
of services. We may disclose health information about you to doctors, nurses, technicians, staff or
other personnel who are involved in taking care of you and your health
For example, your doctor may be treating you for a heart condition and may need to know if you
have other health problems that could complicate your treatment. The doctor may use your
medical history to decide what treatment is best for you. The doctor may also tell another doctor
about your condition so that doctor can help determine the most appropriate care for you.
Different personnel in our organization may share information about you and disclose information
to people who do not work for Arvada Optometric Center in order to coordinate your care, such as
phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. Family
members and other health care providers may be part of your medical care outside this office and
may require information about you that we have. We will request your permission before sharing
health information with your family or friends unless you are unable to give permission to such
disclosures due to your health condition.
• For Payment. We may use and disclose health information about you so that the treatment and
services you receive and Arvada Optometric Center may be billed to and payment may be
collected from you, an insurance company or a third party.
For example, we may need to give your health plan information about a service you received here
so your health plan will pay us or reimburse you for the service. We may also tell your health plan
about a treatment you are going to receive to obtain prior approval or to determine whether your
plan will pay for the treatment.
• For Health Care Operations. We may use and disclose heath information about you in order to
run Arvada Optometric Center and make sure that you and our other patients receive quality care.
For example, we may use you health information to evaluate the performance of our staff in caring
for you. We may also use health information about all or many of our patients to help us decide
what additional services we should offer, how we can become more efficient, or whether certain
new treatments are effective.
We may also disclose your health information to health plans that provide you insurance coverage
and other health care providers that care for you. Our disclosures of your health information to
plans and other providers may be for the purpose of helping these plans and providers provide or
improve care, reduce cost, coordinate and manage health care and services, train staff, and comply
with the law.
[If patients may be contacted for fund raising purposes]
• For Fund Raising. We may contact you to ask for your help with different fund raising
campaigns. Please notify us if you do not wish to be contacted during fund raising campaigns. If
you advise us in writing (at the physical or email address listed at the top of this Notice) that you
do not wish to receive such communications, we will not use or disclose your information for
We may use or disclose health information about you for the following purposes, subject to all applicable
legal requirements and limitations:
• To Avert a Serious Threat to Health or Safety. We may use and disclose health information
about you when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person.
• Required by Law. We will disclose health information about you when required to do so by
federal, state or local law.
• Research. We may use and disclose health information about you for research projects that are
subject to a special approval process. We will ask you for your 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 at the office.
• Organ and Tissue Donation. If you are an organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate such donation and transplantation.
• Military, Veterans, National Security and Intelligence. If you are or were a member of the
armed forces, or part of the national security or intelligence communities, we may be required by
military command or other government authorities to release health information about you. We
may also release information about foreign military personnel to the appropriate foreign military
• Workers’ Compensation. We may release health information about you for workers’
compensation or similar programs. These programs provide benefits for work-related injuries or
• Public Health Risks. We may disclose health information about you for public health reasons in
order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or
neglect, non-accidental physical injuries, reactions to medications or problems with products.
• Health Oversight Activities. We may disclose health information to a health oversight agency
for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary
for certain state and federal agencies to monitor the health care system, government programs, and
compliance with civil rights laws.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health
information about you in a response to a court or administrative order. Subject to all applicable
legal requirements, we may also disclose health information about you in response to a subpoena.
• Law Enforcement. We may release health information if asked to do so by a law enforcement
official in response to a court order, subpoena, warrant, summons or similar process, subject to all
applicable legal requirements.
• Coroners, Medical Examiners and Funeral Directors. We may release health information to a
coroner or medical examiner. This may be necessary, for example, to identify a deceased person
or determine cause of death.
• Information Not Personally Identifiable. We may use or disclose health information about you
in a way that does not personally identify you or reveal who you are.
• Family and Friends. We may disclose health information about you to your family members or
friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to
such a disclosure and you do not raise and objection. We may also disclose health information to
your family or friends if we can infer from the circumstances, based on our professional judgment
that you would not object. For example, we may assume you agree to our disclosure of your
personal health information to your spouse when you bring your spouse with you into the exam
room or the hospital during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present or due to
your incapacity or medical emergency), we may, using our professional judgment, determine that
a disclosure to your family member or friend is in your best interest. In that situation we will
disclose only health information relevant to the person’s involvement in your care. For example,
we may inform the person who accompanied you to the emergency room that you suffered a heart
attack and provide updates on your progress and prognosis. We may also use our professional
judgment and experience to make reasonable inferences that it is in your best interest to allow
another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies,
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other that those identified in the
previous sections without your specific, written Authorization. Examples of disclosures requiring your
authorization include disclosures to your partner, your spouse, your children and your legal counsel.
We also will not use or disclose your health information for the following purposes without your specific,
• For our marketing purposes. This does not include face-to-face communication about products
or services that may be of benefit to you and about prescriptions you have already been prescribed.
• For the purpose of selling your health information. We may receive payment for sharing your
information for, as an example, public health purposes, research, and releases to you or others you
authorize a release to as long as payment is reasonable and related to the cost of providing your
• Any disclosure of your psychotherapy notes. These are the notes that your behavioral heath
provider maintains that record your appointments with your provider and are not stored with your
If you give us Authorization to use or disclose health information about you, you may revoke that
Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or
disclose information about you for the reasons covered by your written Authorization, but we
cannot take back any uses or disclosures already made with your permission.
In some instances, we may need specific, written authorization from you in order to disclose
certain types of specially-protected information such as psychotherapy notes, HIV, substance
abuse, mental health, and genetic testing information for purposes such as treatment, payment and
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other
person you identify, your Protected Health Information that directly relates to that person’s involvement in
your health care. If you are unable to agree or object to such a disclosure, we may disclose such
information as necessary if we determine that it is in your best interest based on our professional judgment.
We may disclose you Protected Health Information to disaster relief organizations that seek your Protected
Health Information to coordinate your care, or notify family and friends of your location or condition in a
disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we
practically can do so.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
• Right to Inspect and Copy. You have the right to inspect and copy your health information, such
as medical and billing records, that we keep and use to make decisions about your care. You must
submit a written request to Arvada Optometric Center in order to inspect and/or copy records of
your health information. If you request a copy of the information, we may charge a fee for the
costs of copying, mailing or other associated supplies. 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. A
modified request may include requesting a summary of your medical record.
If you request to view a copy of your health information, we will not charge you for inspecting
your health information, please submit your request in writing to Arvada Optometric Center. You
have the right to request a copy of your health information in electronic form if we store your
health information electronically.
We may deny your request to inspect and/or copy you record or parts of your record in certain
limited circumstances. If you are denied copies of, or access to, health information that we keep
about you, you may ask that our denial be reviewed, we will select a licensed health care
professional to review your request and our denial. The person conducting the review will not be
the person who denied your request, and we will comply with the outcome of the review.
• Right to Amend. If you believe health information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request an amendment as long as
the information is kept by Arvada Optometric Center.
To request an amendment, complete and submit a medical record amendment/correction form to
Arvada Optometric Center
We may deny your request for an amendment if your request is not in writing or does not include a
reason to support the request. In addition, we may deny or partially deny your request if you ask
us to amend information that;
§ We did not create, unless the person or entity that created the information is no
longer available to make the amendment.
§ Is not part of the health information that we keep.
§ You would not be permitted to inspect and copy
§ Is accurate and complete.
If we deny or partially deny your request for amendment, you have the right to submit a rebuttal
and request the rebuttal be made a part of your medical record. Your rebuttal needs to be 1 page
in length or less and we have the right to file a rebuttal responding to yours in your medical
record. You also have the right to request that all documents associated with the amendment
request (including rebuttal) be transmitted to any other party any time that portion of the medical
record is disclosed.
• Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures.” This is a list of the disclosures we made of medical information about you for
purposes other than treatment, payment, health care operations, when specifically authorized by
you and a limited number of special circumstances involving national security, correctional
institutions and law enforcement.
To obtain this list, you must submit your request in writing to Arvada Optometric Center. It must
state a time period, which may not be longer than six years. Your request should indicate in what
form you want the list (for example, on paper, electronically). The first list you request within a
12-month period will be free. For additional lists we may charge you for the costs 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
health information we use or disclose about you for treatment, payment or health care operations.
You also have the right to request a limit on the health information we disclose about you to
someone who is involved in your care or the payment for it, like a family member or friend. For
example, you could ask that we not use or disclose information about a surgery you had.
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 emergency treatment or we are required
by law to use or disclose the information.
We are required to agree to your request if you pay for treatment, services, supplies and
prescriptions “out of pocket” and you request the information not be communicated to your health
plan for payment or health care or health care operations purposes.
There may be instances where we are required to release this information if required by law.
To request restrictions, you may complete and submit the Request for Restriction on
Use/Disclosure of Medical Information to Arvada Optometric Center.
• Right to Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by email.
To request confidential communications, you may complete and submit the Request for
Restriction On Use/Disclosure of Medical Information and/or Confidential Communication to
Arvada Optometric Center. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or where you wish to be
• Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You
may ask us to fax you a copy of this notice at any time. Even if you have agreed to receive it
electronically, you are still entitled to a paper copy. [You may also find a copy of this Notice on
our web site.]
To obtain such a copy, contact Arvada Optometric Center.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice effective for medical
information we already have about you as well as any information we receive in the future. We will post
the current notice at our office with its effective date on the front page of the notice. You are entitled to a
copy of the notice currently in effect. We will inform you of any significant changes to this Notice. This
may be through our newsletter, a sign prominently posted at our location, a notice posted on our web site or
other means of communication.
BREACH OF HEALTH INFORMATION
We will inform you if there is a breach of your unsecured health information.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the
Secretary of the Department of Health and Human Services at: Office for Civil Rights
To file a complaint with Arvada Optometric Center, contact us at:
Arvada Optometric Center
7913 Allison Way Ste #102
Arvada, CO 80005
You will not be penalized for filing a complaint.
7:00 am - 5:00 pm
8:30 am - 7:00 pm
7:00 am - 5:00 pm
8:30 am - 7:00 pm
7:00 am - 5:00 pm