Privacy Policy

Marietta Eye Clinic Privacy Notice



We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to provide you with this notice about our privacy practices, our legal duties, and your rights concerning your health information. This Notice takes effect June 2018 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice, provided such changes are permitted by applicable HIPPA laws enacted in 1996, and revised in 2013. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy or view the Notice on line.


We use and disclose health information about you for treatment, payment, and healthcare operations:

Treatment: Use or disclose of your health information to a physician or other healthcare provider treating you.

Payment: Use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: Use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Person Involved in Care: We may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses and disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-ray or other similar forms of health information.


Access: You have the right to inspect and obtain a copy of your protected health information, with limited exceptions. By law, you do not have a right to access psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative proceedings; and protected health information which is subject to a law which prohibits access to protected health information. We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger you or another person, or is likely to cause substantial harm to another person referenced within the protected health information. You have the right to request a review of denial to access. Federal and state laws allow healthcare providers 30 days to respond to written request for records. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other costs incurred by us as a result of complying with your request.

Requests for access to your protected health information must be made in writing. Protected health information that is maintained electronically in one or more designated record sets will be provided to you in an electronic format if: (1) you request that such information be provided to you electronically, and (2) if the protected health information is readily producible in the requested electronic form or format. If the protected health information is not maintained in the requested form or format, we will provide you with the protected health information in a readable electronic form or format agreed to by both parties.

Access to Third Parties: We will provide your protected health information to third parties at your request. This request must be in writing and signed by you. The designated third party must be clearly identified by you and you must provide information on where to send your protected health information.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. You must make your request in writing. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. Except as described in the paragraph below, we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You must make your request in writing.

Right to Limit Disclosure to your Health Plan: You have the right to limit disclosure(s) to your health plan if the disclosure is for the purpose of payment or health care operations and is not otherwise required by law, if the service(s) has been paid out of pocket in full by yourself or someone else on your behalf.

Alternative Communication: You have the right to request that we place additional restrictions on our use or disclosure of your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location of your request. We may deny your request under certain circumstances.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Right to Express Complaints: You have the right to express complaints to us and to the Secretary of the Department of Health and Human Services, Office of Civil Rights, if you believe that your privacy rights have been violated. If you wish to complain to us, you must do so in writing, and direct your complaint to the Privacy Officer.

Right to Obtain a Paper Copy of this Privacy Notice: You may request a copy of our Notice at any time.

Right to Notice: We will contact you in the event of a breach of your protected health information, and will provide pertinent information regarding the breach.


For any questions about our privacy practices, contact our Privacy Officer at the number below. You have the right to file a complaint with us or with the Office of Civil Rights. We will not discriminate or retaliate in any way for this action. To file a complaint please contact the applicable party:

Privacy Officer
895 Canton Road, Marietta, GA 30060

U.S. Department of Health and Human Services, Office of Civil Rights