NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
Effective Date: April 1, 2003

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.

If you have any questions or wish to receive additional information about the matters covered by
this Notice of Privacy Practices, please contact Privacy Officer at (585) 232-1111. The Association for the Blind and Visually Impaired-Goodwill of Greater Rochester, Inc. known
as ABVI-Goodwill is required to abide by the terms of this Notice of Privacy Practices (this
ì Noticeî). ABVI-Goodwill reserves the right to change the terms of this Notice at any time. The
revised Notice will apply to all protected health information ABVI-Goodwill received or created
in the past as well as all protected health information ABVI-Goodwill receives or creates in the
future. A current copy of the Notice will be posted in the waiting room of the Low Vision
Center, the lobby of ABVI-Goodwill, and on the ABVI-Goodwill web page. The effective date
of this Notice of Privacy Procedures is set forth on the first page of this Notice. If this Notice of
Privacy Procedures has been changed since your last appointment, ABVI-Goodwill will provide
a copy of the current Notice of Privacy Practices to you when you sign in for your appointment.
Additionally, you may obtain a copy of the current Notice by accessing our web page at
http://www.abvi- goodwill.org or by calling the Low Vision Center at (585) 232-1111 and
requesting that one be sent to you in the mail or by asking for one when you are in the office.
Your ìprotected health informationî consists of all individually identifiable information which is
created or received by ABVI-Goodwill and which relates to your past, present or future physical
or mental health of condition; the provision of health care to you; or the past, present or future
payment for health care provided to you.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WHICH YOUR CONSENT OR AUTHORIZATION IS NOT REQUIRED.

1. Treatment: ABVI-Goodwill will use and disclose your protected health information to
provide, coordinate or manage your health care and related services by ABVI-Goodwill
and other health care providers, including consulting with other health care providers
about your health care or referring you to another health care provider for treatment. For
example, ABVI-Goodwill will disclose your protected health informa tion to a specialist
to whom you have been referred to ensure that the specialist has the necessary
information he or she needs to diagnose and/or treat you.

2. Payment: ABVI-Goodwill will use and disclose your protected health information, as
needed, to obtain payment for the health care ABVI-Goodwill provides to you. For
example, prior to providing services, ABVI-Goodwill may disclose to your insurance
carrier the treatment you are going to receive to ensure that your insurance carrier will
cover that treatment. Additionally, ABVI-Goodwill may disclose to your insurance
carrier, as necessary, the treatment you received to ensure that ABVI-Goodwill is paid or
you are reimbursed for the cost of your treatment.

3. Health Care Operations: ABVI-Goodwill may use or disclose your protected health
information in order to support the business activities of ABVI-Goodwill. These activities
include, but are not limited to, quality assessment and improvement activities, reviewing
the competence or qualification of health care professionals, conducting training programs
in which students provide treatment under the supervision of one of ABVI-Goodwill’s
physicians, business planning and development, and business management and
general administrative activities. For example, ABVI-Goodwill may disclose your protected
health information to medical school students that see patients of ABVI-Goodwill.
Additionally, ABVI-Goodwill may use your protected health information to ensure that
all of the physicians at ABVI-Goodwill provide the highest quality health care.

4. Appointment Reminders: ABVI-Goodwill may use or disclose your protected health
information in order to contact you and remind you of a scheduled appointment.

5. Treatment Alternatives: ABVI-Goodwill may use or disclose your protected health
information to inform you about treatment alternatives.

6. Health Related Benefits and Services: ABVI-Goodwill may use and disclose your
protected health information to inform you about health-related benefits and services that
may be of interest to you.

7. Fundraising Activities: ABVI-Goodwill may use your health information to raise funds
for ABVI-Goodwill. If you do not wish to be contacted for fund raising purposes, please
contact the Department of Marketing and Communications at (585) 232-1111.

8. Others Involved in Your Health Care and Disaster Relief: Unless you object, ABVIGoodwill
may disclose to a family member, other relative, close personal friend or any
other person identified by you protected health information related to that person’s
involvement in your health care or payment related to your health care. ABVI-Goodwill
may also use or disclose to a person responsible for your care your protected health
information that relates to your location, general condition or death. If the opportunity for
you to agree or object to any such disclosure cannot be provided due to emergency
circumstances, ABVI-Goodwill will make these disclosures if they are in your best
interest. Additionally, ABVI-Goodwill may disclose protected health information rela ting
to your location, general condition or death to any public or private entity authorized to
assist in disaster relief efforts.

9. Public Health: ABVI-Goodwill may disclose your protected health information to a
public health authority authorized to collect such information for the purpose of:
a. preventing or controlling disease, injury or disability;
b. reporting disease or injury;
c. reporting vital events such as births or deaths;
d. conducting public health surveillance, public health investigations and public health
interventions;
e. at the direction of a public health authority, to an official of a foreign government
agency acting in collaboration with a public health authority; or
f. reporting child abuse or neglect.

10. Food and Drug Administration: ABVI-Goodwill may disclose your protected health
information to a person subject to the jurisdiction of the Food and Drug Administration
(“FDA”) for the purpose of activities related to the quality, safety or effectiveness of
FDA regulated products.

11. Communicable Diseases: ABVI-Goodwill may disclose your protected health
information, if authorized by law, to a person who may have been exposed to a
communicable disease or may otherwise be at risk of spreading a disease or condition.

12. Employer: ABVI-Goodwill may disclose your protected health information to your
employer if ABVI-Goodwill is providing health care to you at the request of your
employer to conduct an evaluation relating to medical surveillance relating to your
workplace or to evaluate whether you have a work-related illness or injury. ABVIGoodwill
will notify you before your protected health information relating to the medical
surveillance of the workplace and work-related illnesses and injuries is disclosed to your
employer by providing you with written notice at the time ABVI-Goodwill renders health
care to you.

13. Abuse, Neglect or Domestic Violence: ABVI-Goodwill may disclose your protected
health information to a government authority authorized to receive reports of abuse,
neglect or domestic violence if ABVI-Goodwill reasonably believes that you are a victim
of abuse, neglect or domestic violence. Any such disclosure will be made (1) to the extent
it is required by law, (2) to the extent that the disclosure is authorized by statute or regulation
and ABVI-Goodwill believes the disclosure is necessary to prevent serious harm to
you or other potential victims or (3) if you agree to the disclosure.

14. Health Oversight Activities: ABVI-Goodwill may disclose your protected health
information to a health oversight agency for any oversight activities authorized by law,
including audits; investigations; inspections; licensure or disciplinary actions; civil,
criminal or administrative actions or proceedings; or other activities necessary for the
oversight of the health care system, government benefit programs, compliance with
government regulatory program standards or compliance with applicable civil rights
laws.

15. Judicial and Administrative Proceedings: ABVI-Goodwill may, upon certain conditions,
disclose your protected health information in the course of any judicial or administrative
proceeding in response to an order of a court or administrative tribunal, a subpoena,
discovery request, or other lawful process.

16. Law Enforcement Purposes: ABVI-Goodwill may disclose your protected health
information for law enforcement purposes to a law enforcement official:
a. In compliance with a court order, a court-ordered warrant, a subpoena or summons
issued by a judicial officer or an administrative request;
b. In response to a request for informa tion for the purposes of identifying or locating a
suspect, fugitive, material witness or missing person;
c. In response to a request about an individual that is suspected to be a victim of a crime,
if, under limited circumstances, ABVI-Goodwill is not able to obtain your consent;
d. If the information relates to a death ABVI-Goodwill believes may have resulted from
criminal conduct;
e. If the information constitutes evidence of criminal conduct that occurred on the
premises of ABVI-Goodwill; and
f. In certain emergency circumstances, to alert law enforcement of the commission and
nature of a crime, the location and victims of the crime and the identity, or description
and location of the perpetrator of the crime.

17. Coroners, Medical Examiners and Funeral Directors: ABVI-Goodwill may disclose
your protected health information to a coroner or medical examiner for the purpose of
identifying you, determining a cause of death or other duties authorized by law. ABVI-Goodwill may disclose your protected health information to a funeral director, consistent
with all applicable laws, in order to allow the funeral director to carry out his or her
duties.

18. Organ and Tissue Donation: ABVI-Goodwill may disclose your protected health
information to organ procurement organizations or other entities engaged in the procurement,
banking or transplantation of organs, eyes or tissue for the purpose of facilitating
organ, eye and tissue donation and transplantation.

19. Medical Research: ABVI-Goodwill may disclose your protected health information for
research purposes, provided that an institutional review board authorized by law or a
privacy board waives the authorization requirement and provided that the researcher
makes certain representations regarding the use and protection of the protected health
information to be disclosed.

20. Serious Threat to Health or Safety: ABVI-Goodwill may disclose your protected health
information, in a manner which is consistent with applicable laws, if the disclosure is
necessary to prevent or lessen a serious threat to health or safety or the information is
necessary to apprehend an individual.

21. Inmates: ABVI-Goodwill may disclose your protected health information to a correctional
institution or a law enforcement official having lawful custody of you if the correctional
institution or law enforcement official represents that the information is necessary
to (1) provide health care to you; (2) ensure the health and safety of other inmates; (3)
ensure the health and safety of the officers and employees of the correctiona l institution
or the people responsible for transporting the inmates; (4) maintain law enforcement on
the premises of the correctional institution; or (5) administer and maintain the safety,
security and good order at the correctional institution.

22. Workers’ Compensation: ABVI-Goodwill may disclose your protected health information
as authorized by, and in compliance with, laws relating to workers’ compensation
and other similar programs established by law that provide benefits for work-related
illnesses and injuries without regard to fault.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any use or disclosure of your protected health information that is not listed above will be made
only with your written authorization. You have the right to revoke your authorization at any
time, except to the extent that ABVI-Goodwill has already used or disclosed your protected
health information in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

1. Restriction of Use and Disclosure: You have the right to request that ABVI-Goodwill
restrict the protected health information ABVI-Goodwill uses and discloses in carrying
out treatment, payment and health care operations. You also have the right to restrict the
protected health information ABVI-Goodwill discloses to a family member, other relative
or any other person identified by you, which is relevant to such person’s involvement in
your treatment or payment for your treatment. ABVI-GOODWILL IS NOT OBLIGATED
TO AGREE TO ANY RESTRICTION THAT YOU REQUEST. If ABVIGoodwill agrees to a restriction, however, ABVI-Goodwill may only disclose your protected health information in accordance with that restriction, unless the information is needed to provide emergency health care to you.
If you wish to request a restriction on the use and disclosure of your protected health
information, please send a written request to the Privacy Officer which specifically sets
forth (1) whether you are restricting the use or the disclosure of your protected health
information, (2) what protected health information you wish to limit, and (3) to whom
you wish the limits to apply (i.e., your spouse). ABVI-Goodwill will not ask why you are
requesting the restriction. The Privacy Officer will review your request and notify you
whether or not ABVI-Goodwill will agree to your requested restriction.

2. Confidential Communications: You have the right to request that you receive
communications of your protected health information from ABVI-Goodwill in alternative
means or at alternative locations. ABVI-Goodwill will accommodate all reasonable
requests. To request that ABVI-Goodwill make communications of your protected health
information by alternative means or at alternative locations, please send a written request
to the Privacy Officer setting forth the alternative means by which you wish to receive
communications or the alternative location at which you wish to receive such
communications. ABVI-Goodwill will not ask why you are making such a request.
When appropriate, ABVI-Goodwill may condition the provision of a reasonable accommodation
upon receiving information relating to how payment, if any, will be received.

3. Access to Protected Health Information: You have the right to inspect and obtain a
copy of your protected health information that ABVI-Goodwill maintains in a designated
record set, for so long as that protected health information is maintained in a designated
record set. A “designated record set” is a group of records maintained by or for ABVIGoodwill,
which includes billing records and records used in whole or in part to make
decisions about you. You do not have the right to inspect or copy psychotherapy notes,
information compiled in reasonable anticipation of, or for use in, a civil, criminal or
administrative action or proceeding, or information that ABVI-Goodwill is otherwise
prohibited by law from disclosing.

If you wish to inspect or obtain a copy of your protected health information, please send a
written request to the Privacy Officer. If you request a copy of your protected health
information, ABVI-Goodwill may charge a fee for the cost of copying and mailing the
information.

ABVI-Goodwill may, for certain limited reasons, deny your request to inspect or obtain a
copy of your protected health information. If ABVI-Goodwill denies your request, you
may be entitled to a review of that denial. If you are entitled to a review and you wish to
have ABVI-Goodwill’s decision reviewed, please contact the Privacy Officer. The
Privacy Officer will designate a licensed health care professional to review your request.
This reviewing health care professional will not have participated in the original decision
to deny your request. ABVI-Goodwill will comply with the decision of the reviewing
health care professional.

4. Amending Protected Health Information: You have the right to request that ABVIGoodwill
amend your protected health information in a designated record set for so long
as that information exists in a designated record set. To request that an amend ment be
made to your protected health information, please send a written request to the Privacy
Officer. Your written request must provide a reason that supports the requested amendment.
ABVI-Goodwill may deny your request if it does not contain a reason that supports the requested amendment. Additionally, ABVI-Goodwill may deny your request to have your protected health information amended if ABVI-Goodwill determines that (1) the information was not created by ABVI-Goodwill, unless the person or entity that created the information is no longer available to make the amendment; (2) the information is not part of a designated record set; (3) the information is not available for your inspection; or (4) the information is accurate and complete.

5. Accounting of Disclosures of Your Protected Health Information: You have the right
to request a listing of certain disclosures of your protected health information made by
ABVI-Goodwill during the period of up to six (6) years prior to the date on which you
make your request. Any accounting you request will not include (1) disclosures made to
carry out treatment, payment or health care operations; (2) disclosures made to you; (3)
disclosures made pursuant to an authorization given by you; (4) disclosure’s made to other
people involved in your care or made for notification purposes; (5) disclosures made for
national security or intelligence purposes; (6) disclosures made to correctional institutions
or law enforcement officials; or (7) disclosures made prior to April 14, 2003. The right to
receive an accounting is subject to certain other exceptions, restrictions and limitations set
forth in applicable statutes and regulations.

To request an accounting of the disclosures of your protected health information made by
ABVI-Goodwill, please send a written request to the Privacy Officer. Your written
request must set forth the format in which you want the accounting (i.e., hard copy,
electronically, etc.) and the period for which you wish to receive an accounting. ABVIGoodwill
will provide one free accounting during each twelve (12) month period. If you
request additional accountings during the same twelve (12) month period, you will be
charged for all costs ABVI-Goodwill incurs in preparing and providing that accounting.
ABVI-Goodwill will inform you of the fee for each accounting in advance and will allow
you to modify or withdraw your request in order to reduce or avoid the fee.

6. Obtaining a Copy of this Notice: You have the right to request and receive a paper copy
of this Notice of Privacy Practices from ABVI-Goodwill at any time.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with ABVIGoodwill or with the Secretary of Health and Human Services. To file a complaint with ABVIGoodwill, please contact the Security Officer at (585) 232-1111. All complaints must be
submitted in writing.

THE AGENCY WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.

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