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.

THIS NOTICE IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.

Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of
your protected health information. Under the Health Insurance Portability and
Accessibility Act (HIPAA), [Practice Name here] can use your protected health
information for treatment, payment and health care operations.
a) Treatment - We may use or disclose your health information to a physician or
other healthcare provider providing treatment to you.
b) Payment - We may use and disclose your health information to obtain payment
for services we provide you.
c) Health care operations - We may use and disclose your health information in
connection with our healthcare operations. Healthcare operations include quality
assessment and improvement activities, reviewing the competency or qualifications
of healthcare professionals, evaluating provider performance, conducting training
programs, accreditation, certification, licensing or credentialing activities.

Your Authorization
Most uses and disclosures that do not fall under treatment, payment, health care
operations will require your written authorization. Upon signing, you may revoke
your authorization (in writing) through our practice at any time.

Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health
information to a family member, or another person responsible for your care, using
our professional judgment. We will only disclose health information that is directly
relevant to the person's involvement in your healthcare.

Marketing
We will not use your health information for marketing communications without your
written authorization.

Required by Law
We may also use or disclose your health information when we are required to do so
by law.

Abuse or Neglect
We may disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the
victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your or other people's health or safety.

National Security
We may disclose the health information of Armed Forces personnel to military
authorities under certain circumstances. We may disclose health information to
authorized federal officials required for lawful intelligence, counterintelligence and
other national security activities. We may disclose health information of inmates or
patients to the appropriate authorities under certain circumstances.

Appointment Reminders
We may use or disclose your health information to provide you with appointment
reminders via phone, e-mail or letter.

Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in
writing). The request for restriction may be denied if the information is required for
treatment, payment or health care operations.
-You have the right to receive confidential communications regarding your protected
health information.
-You have the right to inspect and copy your protected health information.
-You have the right to amend your protected health information.
-You have the right to receive an account of disclosures of your protected health
information.
-You have the right to a paper copy of this notice of privacy practices. e to comply withLegal Requirements
Kieth J Burkart OD is required by law to maintain the privacy of your protected
health information. We are required to abide by the terms of this notice as it is
currently stated, and reserve the right to change this notice. The policies in any new
notice will not be in effect until they are posted to this site, or are available within
our office.

Complaints
If you have complaints regarding the way your protected health information was
handled, you may submit a complaint in writing to our office. You will not be
retaliated against in any manner for a complaint.

Contact Information
For further information about Kieth J Burkart OD's privacy policies, please
contact Kieth J Burkart OD at the following address or phone number:
Kieth J Burkart OD
29099 Hospital RdSte 201
PO Box 2226
Lake Arrowhead CA 92352
909-337-4310
HIPAA.