New Patient Forms Call (303) 772-3300 to schedule an appointment. Back to Patient Info Step 1 of 5 20% ECCNC takes the privacy and security of your personal information very seriously. All data submitted through the form on this page is transmitted and stored using HIPAA compliant encryption technology. If you don’t feel comfortable providing information in a specific box then please write the following in the box: “Please ask”. Do you have an appointment scheduled?*YesNoDate of Appointment:It may take up to 48 hours to process online forms. If your appointment is within 48 hours, please complete forms at the office when you arrive instead of completing online. Date Format: MM slash DD slash YYYY Patient InformationName* First Last GenderMartial StatusBirth Date* MM DD YYYY AgeSocial Security NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry Emergency ContactEmergency Contact PhonePhoneHomePhoneWorkPhoneCellHow did you hear of us?Email* EmployerOccupationEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry PharmacyPharmacy PhonePrimary Care PhysicianReferring PhysicianMedical InsuranceName & Address PolicyholderRelationship CopayPolicy IDGroup ID Guarantor (Person to be billed, if different than patient)Name First Middle Last GenderMartial StatusBirth Date MM DD YYYY Social Security NumberAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificState ZIP Code PhoneHomePhoneWorkPhoneCellEmployer NameOccupationEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry HIPAA Approved ContactsName First Middle Last RelationshipPhoneHomePhoneWorkPhoneCellI would like to add another HIPAA contactName First Middle Last RelationshipPhoneHomePhoneWorkPhoneCellCMS / ONC Electronic Health Record requirement.EthnicityRaceLanguage Health HistoryList Please check the conditions that YOU have experienced: Cataracts Corneal Problems Diabetic Changes Eye Injury Eyelid Problems Eye Muscle Problems Glaucoma Lazy Eye Macular Degeneration Retinal Problems If you checked any of the conditions above, please provide details: Please check the conditions that a blood RELATIVE has experienced: Cataracts Corneal Problems Diabetic Changes Eye Injury Eyelid Problems Eye Muscle Problems Glaucoma Lazy Eye Macular Degeneration Retinal Problems Other: Prior Eye Surgeries – Please list procedure and date of surgery History of Medical Conditions Mark conditions that apply to youPlease check the conditions that YOU have experienced: Arthritis Cancer Cardiovascular Diabetes Gastrointestinal Hematological Infections Neurologic Psychiatric Pulmonary Thyroid If you checked any of the conditions above, please provide details: Please check the conditions that a blood RELATIVE has experienced: Arthritis Cancer Cardiovascular Diabetes Gastrointestinal Hematological Infections Neurologic Psychiatric Pulmonary Thyroid Other: Social HistoryDo you drive?YesNoDo you drink alcohol?YesNoHow much per day / week / month:Do you smoke?YesNoHow many packs per day:Do you use Medical Marijuana?YesNoDo you use recreational drugs?YesNoMedicationsPlease list medication name, dose and frequency. Also, include any vitamins and over the counter supplements. Drug AllergiesPlease list any drug allergies and your reaction to the medication. EYE CARE CENTER OF NORTHERN COLORADO, P.C. POLICIESWe find that our clients appreciate knowing in advance what is expected of them financially and what terms and conditions are available. Please read the following information carefully. “I” refers to the patient, the guarantor for a patient under 18 years of age, or a legally authorized signer for a patient who is handicapped. If you should have any questions, please direct them to our Business Office. The Eye Care Center of Northern Colorado, P.C., will be known as ECCNC in this document. REFERRALS*I understand that it is my responsibility to obtain a referral through my Primary Care Physician’s office if one is required by my insurance carrier(s). Failure to do this will result in the charges being billed directly to me.ASSIGNMENT OF MEDICAL BENEFITS*I authorize my insurance carrier(s) to assign all surgical and or medical benefits, if applicable, to the ECCNC. I also authorize release of medical information necessary to process all medical insurance claims.PATIENT PAYMENT*I understand that all fees must be paid at the time the service is provided. Payment may be made by cash, check, or accepted credit card (VISA, MasterCard, or Discover). Any other payment arrangement must be authorized in advance by the ECCNC Business Office.INSURANCE*I understand that my current insurance card(s) and an identity are to be presented at each visit. Failure to do this will result in my being billed directly. I also understand that co-payments are to be paid at the time of service in the form of cash, check, or accepted credit card. I understand that billing my insurance is done as a courtesy and that the ECCNC will not be responsible for collecting overdue insurance claims or negotiating settlement on disputed claims. My insurance company is required by the Colorado Insurance Commissioner to process, pay, or reject all insurance claims within 30 days. The ECCNC will file based on the information I provide at time of service. If the ECCNC is contracted with my insurance carrier(s), I understand that they will accept the contracted rate for the charges billed. I will be responsible for any balance my insurance deems patient responsibility/non-payable/non-covered, and I will make payment in full upon receipt of statement or by payment arrangement authorized by the ECCNC Business Office in advance. I understand that if I fail to pay my account in full within 60 days of becoming patient responsibility, a $10 Rebilling Fee will be added to my account and the account will be subject to collections. I also understand that if I make payment by check and it is returned for Non-Sufficient Funds, a $25 Returned Check Fee will be added to my account and I will have to make future payments by cash, money order, or accepted credit card.VSP (GLASSES) INSURANCE*I understand that VSP will be billed on my behalf for appointments scheduled as “Well-Eye (Routine) Exams” and for prescription glasses or contact lens.OPTICAL*I understand that all optical goods, contacts, or medical devices must be paid for in full (or according to my insurance) at the time they are ordered as they are custom-fitted for me individually.COLLECTIONS*I understand that if I fail to make payment on my account, the account will be turned over to an outside collection agency. I also understand that a $50 Collection Fee will be added to my account and my family and I will be discharged from being seen by any doctor at the ECCNC. I acknowledge that I will be responsible for all legal costs including collection fees and attorney fees if I fail to pay my account.MISSED APPOINTMENTS / CANCELLATIONS*I understand that I am responsible to show up on time for my scheduled appointment. If I am late, I acknowledge that if possible I will be given the option to be worked into the schedule with an undetermined wait time or have my appointment rescheduled. I understand that the first time I miss or cancel my appointment within 24 hours I will receive a reminder letter. The second time I miss or cancel my appointment, I will be charged a $30 Cancellation Fee. I understand that if subsequent appointments are missed or cancelled with short notice, I may be discharged from the practice. I also understand that multiple patients scheduling appointments together must cancel no later than 48 hours prior to the scheduled appointment or each person will be charged a $30 Cancellation Fee.NOTICE OF PRIVACY*The Eye Care Center of Northern Colorado follows HIPAA and privacy policy guidelines; a copy is available upon request. NOTICE OF PRIVACY PRACTICESEye Care Center of Northern Colorado 1400 Dry Creek Drive, Longmont, CO 80503 303-772-3300 Micah Rothstein, M.D., Privacy OfficerEffective Date: November 1, 2013 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. We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.We make a record of the medical care we provide and may receive such records from others.We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information.It also describes your rights and our legal obligations with respect to your medical information.If you have any questions about this Notice, please contact our Privacy Officer listed above.Table of ContentsA. How This Medical Practice May Use or Disclose Your Health Information B. When This Medical Practice May Not Use or Disclose Your Health Information C. Your Health Information Rights Right to Request Special Privacy Protections Right to Request Confidential Communications Right to Inspect and Copy Right to Amend Right to an Accounting of Disclosures Right to a Paper or Electronic Copy of this Notice D. Changes to this Notice of Privacy Practices E. Compliants A. How This Medical Practice May Use or Disclose Your Health Information This medical practice collects health information about you and stores it in a chart and on a computer and in an electronic health record/personal health record. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes: Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test.We may also disclose medical information to members of your family or others who can help you when you are sick or injured, or after you die. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you. Health Care Operations. We may use and disclose medical information about you to operate this medical practice.For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals.We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your medical information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patientsafety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share medical information about you with the other health care providers, health care clearinghouses and health plans that participate with us in "organized health care arrangements" (OHCAs) for any of the OHCAs' health care operations. OHCAs include hospitals, physician organizations, health plans, and other entities which collectively provide health care services. A listing of the OHCAs we participate in is available from the Privacy Official. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office.We may also call out your name when we are ready to see you. Notification and Communication with Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death.In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts.We may also disclose information to someone who is involved with your care or helps pay for your care.If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, recommend that you participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you.We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities. Public Health. We may, and are sometimes required by law to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm. Health Oversight Activities. We may, and are sometimes required by law to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order.We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student if you have agreed to the disclosure on behalf of yourself or your dependent. Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody. Worker's Compensation. We may disclose your health information as necessary to comply with worker's compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition.We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current email address, we may use email to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate. Psychotherapy Notes. We will not use or disclose your psychotherapy notes without your prior written authorization except for the following: 1) your treatment, 2) for training our staff, students and other trainees, 3) to defend ourselves if you sue us or bring some other legal proceeding, 4) if the law requires us to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities concerning your psychotherapist, 6) to avert a serious threat to health or safety, or 7) to the coroner or medical examiner after you die. To the extent you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes. Research. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law. Fundraising.We may use or disclose your demographic information, the dates that you received treatment, the department of service, your treating physician, outcome information and health insurance status in order to contact you for our fundraising activities.If you do not want to receive these materials, notify the Privacy Officer listed at the top of this Notice of Privacy Practices and we will stop any further fundraising communications. Similarly, you should notify the Privacy Officer if you decide you want to start receiving these solicitations again. B. When This Medical Practice May Not Use or Disclose Your Health Information Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. C. Your Health Information Rights Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed.If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address.We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions.To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, we will provide your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary, as allowed by federal [and state] law. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional. Right to Amend. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial.We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices. D. Changes to this Notice of Privacy Practices We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received.We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment: www.eyecaresite.com E. Complaints Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Region VIII - Denver (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Velveta Howell, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 999 18th Street, Suite 417 Denver, CO 80202 Voice Phone (800) 368-1019 FAX (303) 844-2025 TDD (800) 537-7697 OCRMail@hhs.gov The complaint form may be found at:www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint. © 2002-2013 by PrivaPlan® Associates, Inc. Patent Pending. All Rights ReservedAcknowledgement of Receipt of Notice of Privacy PracticesI hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.Eye Care Center of Northern Colorado 1400 Dry Creek Drive, Longmont, CO 80503 303-772-3300 Micah Rothstein, M.D., Privacy OfficerSignaturePatient's or Authorized Person's SignatureConsentI the undersigned give my authorization to treat and assign directly to Eye Care Center of No. Co. all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all approved and covered charges whether or not paid by insurance. I acknowledge receipt of the Practice's Notice of Privacy Practices. I authorize the Practice to use and disclose my health information for purposes of treatment, obtaining payment of benefits and for services rendered. I consent to be contacted by mail, email or cell phone regarding any matter related to my Eye Care Center accounts by the provider, creditor, its successors, 3rd party collection agencies or assigns. This consent includes contact information that I may provide and includes phone calls that employs auto-dialer technology and prerecorded messages. To revoke consent to call my cell phone, I agree to provide notice by mail to Eye Care Center of No. Co. 1400 Dry Creek Dr. Longmont, Co 80503Signature Date* MM DD YYYY Patient Name* First Last I would like to receive a copy of any amended Notice of Privacy Practices by e-mail If not signed by the patient, please indicate relationship Parent or guardian of minor patient Guardian or conservator of an incompetent patient Signee Name (if not patient) First Last NameThis field is for validation purposes and should be left unchanged.