NOTICE OF PRIVACY PRACTICES

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

Sandhill Ocular Prosthetics LLC is committed to protecting the privacy and confidentiality of health information created and/or maintained at our facility. Federal and state regulations require us to maintain the privacy of your health information and to implement policies and procedures to safeguard the confidentiality of your health information. We are required by law to provide you with this Notice of Privacy Practices.

This notice provides you with information about our privacy practices and describes the ways in which we may use or disclose your health information. The notice also describes your rights and our legal obligations regarding any such uses or disclosures. It applies to all of your health information created and/or maintained at our facility, including any information that we receive from other health care providers. If you have any questions about this notice, please contact our Privacy Officer listed below.

We reserve the right to change this notice and to make the revised notice effective for all health information we already have about you as well as any information we create or receive in the future. We will make the revised notice available to you upon request on or after the effective date of the revised notice and will have a copy of the notice available at our facility to take with you. We will post a copy of the current notice in our facility. We will follow the terms of the notice that is currently in effect.

Privacy Officer: Kori Malouin
Email: kori@sandhillocular.com
Address: 112 Treemonte Drive, Orange City, Florida 32763

A. How Sandhill Ocular Prosthetics LLC May Use or Disclose Your Health Information

Sandhill Ocular Prosthetics LLC collects health information about you and stores it in an electronic chart. This is your medical record. The medical record is the property of Sandhill Ocular Prosthetics LLC, 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 may use your health information to provide you with health care treatment and services. Our facility healthcare team will share information about you in order to coordinate your care. We may disclose your health information to doctors, therapists, or other personnel who are involved in taking care of you. For example, physicians involved in your care will need information about your symptoms in order to determine the course of treatment that should work best for you. We may also disclose health information about you to a healthcare facility, pharmacy or family member who will be involved in your care once you have been discharged from our facility, including your Power of Attorney if you have one.

Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health insurance 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. For example, we may provide an ambulance transport company your information so they may receive payment for services they have provided you.

Health Care Operations. We may use and disclose medical information about you to operate Sandhill Ocular Prosthetics LLC. 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.

Individuals involved in your care or payment for your care. 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 (Power of Attorney) about your location, your general condition or, unless you have instructed us to do otherwise, in the event of your death.

Other Permitted or Required Uses and Disclosures. We may use and disclose your health information for reasons permitted by the Health Insurance Portability & Accountability Act (HIPAA) Rule including, but not limited to the following:

When required by the Secretary of Health and Human Services
As required by law
Public health activities
Health oversight activities
Change of ownership
Proof of Immunization
Judicial or administrative proceedings
Workers' Compensation
Law enforcement officials
Coroners, medical examiners, or funeral directors
Research
To avert a serious threat to public health or safety
Specified government functions

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke a written authorization at any time as long as your revocation is provided to us in writing.

Website Analytics. We do not currently collect any website analytics, tracking data, or usage statistics from visitors to our website. No personal information is gathered through website visits.

B. When Sandhill Ocular Prosthetics LLC May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Sandhill Ocular Prosthetics LLC will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize Sandhill Ocular Prosthetics LLC 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 family member's 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 obtain a copy of it. 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.

Right to Amend or Supplement. 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 any denial and how you can disagree with the denial.

Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by Sandhill Ocular Prosthetics LLC, except that Sandhill Ocular Prosthetics LLC 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), 4 (individuals involved in your care or payment for your care) and 5 (other permitted or required uses and disclosures) of Section A of this Notice of Privacy Practices.

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.

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 above.

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 the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Practices 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 available in our lobby and upon request.

E. Complaints

Complaints about this Notice of Privacy Practices or how Sandhill Ocular Prosthetics LLC handles your health information should be directed to our Privacy Officer listed above.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint in writing to:

Department of Health Inspector General
4052 Bald Cypress Way, BIN A03
Tallahassee, FL 32399-1704
850-245-4141

Secretary of the US Department of Health and Human Services
200 Independence Ave, SW
Washington, DC 20201
202-619-0257

Revised 01/20/2025