NOTICE OF PRIVACY PRACTICES
Lum Optometry I Randall T. Lum, O.D.
951 EI Camino Real, So. San Francisco, CA 94080 (650) 589-7198

This notice is required by law to inform you of how your health information will be protected, how Dr. Lum and office staff may use and disclose your health
information whether electronically, on paper or orally and how you can get access
to this information. We are required by federal law to protect the privacy of your
health information, to establish policies and procedures that govern the behavior
of our workforce and business associates, and provide this notice about our
privacy practices, and abide by the terms of this notice. Please review this notice
carefully.
Each time you visit our office a record of your visit is made. Typically, this record
contains a description of your symptoms, medical history, examination and test
results, diagnoses, treatment, a plan for future care, and examination and
materials payments. Understanding what is in your record and how your health
information is used helps you to ensure its accuracy, to better understand how
others may access and use your health information and to make more informed
decisions when authorizing disclosures to others.
We may use and disclose your medical records for each of the following purposes: treatment,
payment and health care operations.
„X Treatment means providing, coordinating, or managing health care and related services
by one or more health care providers. An example would be an eye examination.
„X Payment means such activities as obtaining reimbursement for services, confirming
coverage, billing or collection activities, and utilization review. An example would be
sending a bill for your visit to your insurance company for payment.
„X Health care operations include the business aspects of running our practice,
management analysis, and customer service. An example would be an internal quality
assessment review.
With respect to your medical and billing records kept by Lum Optometry / Randall T. Lum,
O.D., you have the right to:
„X Authorize the use of your health information. Before we use or disclose your health
information, other than as described below, we will obtain your written authorization.
„X Access your health information. You may request to inspect or make a copy of your
health information kept in your record. Your request must be submitted in writing. We
may charge for the cost of providing you access and for your copies.
„X Amend your health information. If you at any time believe that we have incorrect or
incomplete information about you, you may request that we correct or add information.
This request must also be done in writing.
„X Request confidential communications. You may request that, when we communicate
with you about your health information, we do so in a specific way (e.g. at a certain mail
address or phone number). We will make every reasonable effort to agree with your
request.
„X Limit our use or disclosure of your health information. You may request in writing
that we restrict the use or disclosure of your health information for treatment, payment,
health care operations or any other purpose except when specifically authorized by you,
when we are required by law, or in an emergency situation in order to treat you. You may
restrict these disclosures to other family members, other relatives, close personal friends,
or any other person identified by you. We will consider your request and respond, but we
are not legally required to agree if we believe your request would interfere with our ability
to treat you or collect payment for our services. If we do agree to a requested restriction,
we must abide by it unless you agree in writing to remove it.
„X Receive an accounting of disclosures. You may request a list of disclosures of your
health information that we have made for reasons other than treatment, payment or
health care operation. Disclosures that we make with your authorization will not be listed.
„X Obtain a copy of this notice. We will gladly provide a copy for your own records at no
charge.
We may use your medical information to:
„X Recall: We may contact you to provide appointment reminders by mail or telephone.
„X Offer Treatment and Services. We may use your health information to provide you with
information about our health care services, new treatments and other health-related
benefits and services that may be of interest of you.
„X Fax Request. If we receive a fax requesting your prescription for an order you have
requested, you authorize us to release that information by fax or telephone.
„X Public health. We may disclose your information as required by law to public health or
legal authorities charged with preventing or controlling disease, injury or disability.
Any other uses or disclosures will be made only with your written authorization. You may revoke
such authorization in writing and we are required to honor and abide by that written request,
except to the extent that we have already taken actions relying on your authorizations. We are
unable to take back any disclosure we have already made with your permission.
We are required to abide be the terms of the Notice of Privacy Practices currently in effect. We
reserve the right to change the terms of our Notice of Privacy Practices and to make the new
notice provisions effective for all protected health information that we maintain. We will post and
you may request a written copy of a revised Notice of Privacy Practices from this office.
You may contact our Privacy Officer at any time with question regarding any of the information in
the Notice of Privacy Practices or to provide us with written request or instructions regarding your
information.
If you believe we have not properly protected your privacy, have violated your privacy rights, or
you disagree with a decision we have made about your rights, you may contact our Privacy
Officer by phone at (650) 589-7198 or you may send a written complaint. You may also send a
written complaint to the U.S. Department of Health and Human Services at 200 Independence
Avenue, S.W. Washington, D.C. 20201. The care that you receive at our facility will in no way be
impacted if you file a complaint. Effective 4/14/03.