Your Information. Your Rights. Our Responsibilities.

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Your Rights 

You have several rights regarding your health information. You have the right to obtain a copy of  your health and billing records, as well as to request corrections if you believe any information is  incorrect or incomplete. You may also ask us to communicate with you in a specific manner, such as  by calling your cell phone rather than your home phone. You can request that we restrict the  sharing of certain health information, and while we are not required to agree in all circumstances,  we will honor restrictions whenever possible. You have the right to request an accounting of  disclosures, which is a list of who we have shared your information with, other than for treatment,  payment, or healthcare operations. Finally, you may request a paper or digital copy of this Privacy  Policy at any time. 

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Our Uses and Disclosures 

We use your health information in several ways. First, we use it to provide and coordinate your  treatment. We may also use your information to bill you, your insurance company, or other  responsible parties, and to obtain payment for services. Your information may be used in the daily  operations of our practice, such as improving the quality of care and contacting you when  necessary. In some situations, we may be required by federal, state, or local law to share your  information, such as for public health reporting or safety concerns. We will never sell your  information or use it for marketing purposes without your written permission. 

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Our Responsibilities 

We are legally required to maintain the privacy and security of your protected health information. If  a breach occurs that may compromise your information, we will notify you promptly. We are  obligated to follow the duties and privacy practices described in this notice, and we will not use or  disclose your information for purposes other than those outlined here unless you provide written  authorization. 

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Contact Information 

If you have questions about this notice or wish to exercise your rights, please contact us at: 

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San Ramon Optometric Group 

2723 Crow Canyon Road, Suite 102 

San Ramon, CA 94583 

Phone: (925)831-1084 

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Acknowledgment of Receipt 

I acknowledge that I have received and reviewed a copy of this Privacy Policy Notice. 

 

Patient Name: __________________________ 

Signature: _____________________________