Henry Ford OptimEyes 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.

Henry Ford OptimEyes is required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Uses and Disclosures
Your health information may be used by corporate staff members, franchise owners and staff members, trainees and externs, or disclosed to other health care professionals (including outside labs when necessary) for the purpose of evaluating your health, diagnosing optical and / or medical conditions, and providing services, products and treatment. Your health information may also be used to seek payment from your health plan(s), from other sources of coverage such as a supplemental insurer, or from credit card companies that you may use to pay for services. It may also be forwarded and utilized by a contracted collection agency for unpaid balances.

Your health information may be used as necessary to support the day-to-day activities and management of Henry Ford OptimEyes. Your health information may also be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send your appointment reminders.

Information About Treatments
Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.

Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Individual Rights
You have certain rights under the Federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your protected health information

• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice

Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in Federal and State laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by Federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by going to your local Henry Ford OptimEyes office or contacting The Compliance Board at our Corporate office. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

The Compliance Board
Henry Ford OptimEyes
655 W. 13 Mile Road
Madison Heights, MI 48071

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter, to the above address, describing the cause of your concern. You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:

The Compliance Board
Henry Ford OptimEyes
655 W. 13 Mile Road
Madison Heights, MI 48071
(248) 588-9300

Effective Date
This notice is effective on or after April 14, 2003.