Dedicated to excellence in care for the back of the eye®


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.

Retina & Macula Specialists respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us or do so, or unless the law authorizes or requires us to do so. The law protects the privacy of health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For Treatment:
Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used to help decide what care may be right for you.
We may also provide information to others providing you care. This will help them stay informed about your care.

For Payment:
We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses; procedures performed, or recommended care.

For Health Care Operations:
We use your medical records to assess quality and improve services.
We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
We may contact you to remind you about appointments and give you information about treatment alternatives or other health related benefits or services.
We may contact you to raise funds.
We may use and disclose your information to conduct or arrange for services, including
medical quality review by your health plan accounting, legal, risk management, insurance services, and audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Right:
The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you. You have the right to:

  • Receive, read, and ask questions about this Notice.
  • Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request however; we will comply with any request granted.
  • Request and receive from us a paper copy of the most current Notice of Privacy Practices for your protected health information.
  • Request to see and get a copy of your protected health information.
  • Request in writing a review of a “Denial of Access” to your health information.
  • Request in writing a change to your health information, except in certain instances.
  • Write a statement of disagreement if your request is denied in reviewing your health information. It will be stored in your medical record, and included with any release of your records. We have a form available to respond to this type of request.
  • To ask that your health information be given to you by another means or at another location. A request in writing is needed with a signature and date.
  • To cancel a prior authorization to use or disclose health information that has already been released however, it does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

When you request, we will give you a list of disclosures of your health information. The list will not include disclosures to third-party payers. You may receive this information without charge once every 12 months. We will notify you of the cost if you request this information more than once in 12 months.

For help with these rights during normal business hours, please contact our Compliance Officer.

Our Responsibilities:
We are 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.
  • Accommodate reasonable requests in regards to your health information.
  • Respond to each of your requests within ten consecutive days under normal circumstances. If special arrangements are necessary, we will notify you in writing.
  • For your benefit, this Notice is made available on our Website at this address

To ask for Help or Complain:
If you have questions, want more information, or want to report a problem about the handling of your protected health information you may contact our Compliance Officer.

If you believe your privacy rights are violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to our Compliance Officer at our Tacoma Office Facility. You may also file a complaint with the US Secretary of Health and Human Services. We respect your right to file a complaint with us or with the US Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information
Notification to Family and Others:
Unless you object, we may release information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. You have the right to object to this use or disclosure of your information. If you object, we will not use it or disclose it.

We may use and disclose your protected health information without prior authorization as follows:

  • With Medical Researchers – If your research is approved and policies are in place to protect the privacy of your health information, we may share information with the medical researchers conducting the research.
  • To Funeral Directors/Coroners – We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
  • To Organ Procurement Organizations – Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
  • To the Food and Drug Administrative (FDA) – We may disclose to the FDA health information relative to adverse events with respect to food, supplements. product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
  • For Public Health and Safety Purposes as Allowed or Required by Law – As required by law, we may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury, and disability.
  • To Report Suspected Abuse or Neglect to public authorities – We may disclose your Protected Health Information to a public health or other appropriate government authority authorized by law to receive reports of child abuse or neglect. Further, we may disclose Protected Health Information about an individual whom we believe to be a victim of abuse, neglect, or domestic violence if you agree or when required by law.
  • For Law Enforcement Purposes – We may release your Protected Health Information if asked to do so by law enforcement official.
  • For Health and Safety Oversight Activities – We may disclose your Protected Health Information to a health oversight agency for activities authorized by law and as necessary for the government to monitor the health care system, government programs and compliance with civil rights law. These oversight activities may include audits, investigations, inspections and licensure.
  • Correctional Institution – Should you be an inmate of a correctional institution, we may disclose to the institution or agents there of health information necessary for your health and the health and safety of another individual.
  • For Disaster Relief purposes – We may use and disclose your Protected Health Information when necessary to prevent or lesson a serious threat to the health and safety of a person or the public.
  • For Work-related Conditions that Could Affect Employee Health – We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
  • To the Military Authorities of U.S. and Foreign Military Personnel – We may disclose the Protected Health Information of Armed Forces personnel, veterans and foreign military personnel for authorized activities under the appropriate circumstances. Further, your Protected Health Information may be disclosed to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities and special investigations, including the provision of protective services to the President and other authorized persons or foreign heads of state, as authorized by law.

Use and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

We reserve the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and requesting it, or personally picking it up at our office.
Effective Date: April 14, 2003

Dedicated to excellence in care for the back of the eye®


We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so.
You may see your record or get more information about it by contacting our Compliance Officer.

Our Notice of Privacy Practices describes in more detail how your health information may be used, disclosed; and how you can access your information.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

Patient or legally authorized
Patient Name Relationship

if signed on behalf of the patient (parent, legal guardian, personal representative)
(Notation, if any, by staff)

___ Patient chooses not to sign form.
___ Patient informed that we will only speak with him/her about their
medical care, except those entities that do not need any authorization to request such information.

This form will be retained in your medical record.

© 2015 Retina & Macula Specialists • All rights reserved.