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Notice of Privacy Practices Lakeshore Vision Centers

1021 Jefferson Street Algoma, WI 54201


1217 Ellis Street, Kewaunee, WI 54216


Dr. John Gorz, Privacy Official

We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.


The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not.

Examples of how we might use or disclose health information for treatment purposes might include:

Setting up or changing appointments including leaving messages with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails or emails; calling your name out in a reception room environment; prescribing glasses, contact lenses, or medications as well as relaying this information to suppliers by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills; notifying you that your ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails or emails; referring you to another doctor for care not provided by this office; obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health; sending you postcards or letters or leaving messages with those at your home who may answer the phone or on answering machines, voice mails or emails reminding you it is time for continued care; at your request, we can provide you with a copy of your medical records via email transmission.

Examples of how we might use or disclose health information for payment purposes might include:

Asking you about your vision or medical insurance plans or other sources of payment; preparing and sending bills to your insurance provider or to you; providing any information required by third party payors in order to insure payment for services rendered to you; sending notices of payment due on your account to the person designated as responsible party or head of household on your account with fee explanations that could include procedures performed and for what diagnosis: collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney’s office. At the patient’s request we may not disclose health care information that you have paid for out of pocket. This only applies to those encounters related to the care you want restricted.

Examples of how we might use or disclose health information for business operations might include:

Financial or billing audits; internal quality assurance programs; participation in managed care plans; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; Medicare or Medicaid audits; providing information regarding your vision status to the Department of Public Safety, a school nurse, or agency qualifying for disability status.


In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could.

• When a state or federal law mandates that certain health information be reported for a specific purpose

• For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices

• Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime

• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative hearings

• Disclosures to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial

• Disclosures to organizations that handle organ or tissue donations

• Uses or disclosures for health related research

• Uses or disclosures to prevent a serious threat to health or safety of an individual or individuals

• Uses or disclosures to aid military purposes or lawful national intelligence activities

• Disclosures of de-identified information

• Disclosures related to a workman’s compensation claim

• Disclosures of a “limited data set” for research, public health, or health care operations

• Incidental disclosures that are an unavoidable by-product of permitted uses and disclosures

• Disclosure of information needed in completing forms from a school related vision screening, information to the Department of Public Safety, information related to certification for occupational or recreational licenses such as pilots license.

• Disclosures to business associates who perform health care operations for Lakeshore Vision Centers and who commit to respect the privacy of your information. We also require any business associate to require any sub-contractor to comply with our privacy policies.

• Unless you object, disclosure of relevant information to family members or friends who are helping you with your care or by their allowed presence cause us to assume you approve their exposure to relevant information about your health

• Upon your death, we may disclose to your family members or other persons who were involved in your care or payment for health care prior to your death health information relevant to their involvement in your care.


It is the policy of Lakeshore Vision Centers for our staff to take phone calls from individuals on a patient’s behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Lakeshore Vision Centers staff will also assist individuals on a patient’s behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s vision or health status may be disclosed without proper patient consent. Lakeshore Vision Centers staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual.


The following are some specific uses and disclosures we may not make of your health information without your authorization:

Marketing Activities

Sale of Health Information – We do not currently sell or plan to sell your health information.

Psychotherapy Notes – Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.

You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.

We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.

We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.


The law gives you many rights regarding your personal health information.

You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to the Privacy Officer named at the beginning of this Notice. We do not have to agree to your request, but if we agree, must honor the restrictions you ask for.

You may ask us to communicate with you in a specific confidential manner. An example might be only contacting you by telephone at your home. We will accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred in accommodating your request. Requests for special communication requests must be made to the Privacy Officer named at the beginning of this Notice. We will reserve the right to determine if we will be able to continue your treatment under authorizations which are too restrictive.

You may ask to review or get copies of your health information. There are a very few limited situations in which we may refuse your access to your health information. For the most part we are happy to provide you with the opportunity to either review or obtain a copy of your medical information. All requests for review or copy of medical information must be made in writing to the Privacy Officer named at the beginning of this Notice. While we usually respond to these requests in just a day or so, by law we have fifteen (15) days to respond to your request. We may request an additional thirty (30) day extension in certain situations. Copies of Health care information you request may be delivered to you in electronic format. The e-format Lakeshore Vision Centers has approved as secure is the patient web portal through Crystal Software.

You may ask us to amend or change your health care information if you think it is incorrect or incomplete. Your written request and reasons in support of the request for change must be sent to the Privacy Officer named at the beginning of this Notice. If we agree, we will make the amendment to your medical record within thirty (30) days of receipt of the request. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include.

You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years (or a shorter period if you wish). Routine disclosures would include those used during treatment, payment, and business operations of Lakeshore Vision Centers. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $20.00 per list. We will usually respond to your written request (made to the Privacy Officer named at the beginning of this Notice) within thirty (30) days but we are allowed one thirty (30) day extension if we need the time to complete your request.

You may obtain additional copies of this Notice of Privacy Practices from our business office.


By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time.

If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website, with copies available upon request.


If you think that anyone at Lakeshore Vision Centers has not respected the privacy of your health information, you are free to complain to the Privacy Officer named at the beginning of this Notice. We are more than happy to try to resolve any concern you may have in writing. If we cannot resolve your concern at that level, you may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the state Attorney General’s Office. We will not retaliate against you if you make such a complaint.