HIPPA release information

Marketing Health Products or Services: We will not use your health information for marketing
communications without your prior written authorization. We may provide you with
information regarding products or services we offer related to your health care needs. We will
never sell your health information without your prior authorization.

To You, 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, to other persons to the extent necessary to help with your
healthcare or payment for your services, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the
notification of ( including identifying or locating) a family member, your person 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 information, we will provide you with an
opportunity to object to such uses or disclosures, In the event of your incapacity or emergency
circumstances, we will disclose health information bases on a determination using our professional
judgment disclosing only health information that is directly relevant to the person’s involvement in
your healthcare. We will also use our professional judgment ad 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-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so
by law, including judicial and administrative proceedings.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we
reasonably believe that you are possible victim of abuse, neglect, or domestic violence or the
possible victim, of other crimes, we may disclose your health information to the extent
necessary to avert a serious-threat to your health safety or safely to others.

National Security: We may disclose to military authorities the health information of armed
forces personal under certain circumstances, we may disclose to authorize federal officials;
health information required for lawful intelligence, counterintelligence and other national
security activities. We may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders (such as voice mail messages, postcards, or letters) or information about
treatment alternatives or other health related benefits and services that may be of interest to you

PATIENT RIGHTS
Access: you may ask to review-or- get copies of your health information, There are a 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 receptionist on duty. 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 request an additional thirty (30) day
extension in certain situations. We will charge you a reasonable cost-based fee for expenses
such as copies and staff time.

Disclosure Accounting: You may request a list of any non-routine disclosure of your health
information that we might have made with the past five (5) years (or a shorter period if you
wish), but not for a disclosure made prior to January 1, 2004. Routine disclosures would include
those used in your treatment, payment and business operations. 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 $10.00 per list. We will usually respond to your written request with in fifteen (15) days
but we are allowed a thirty (30) day extension If we need the time to complete your request.

Restriction: 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 receptionist on duty. We do not have to agree to your request.

Alternative Communication: You may ask in writing that we communicate with you about your
health information by alterative means or locations. Your request must specify the alternative
means or location, and provide satisfactory explanation how payments will be handled under
alternative means or location you request.

Amendment: You may ask us to amend or change your health care information if you think it is
incorrect or incomplete. If we agree, we will make the change to your medical record with in
thirty (30) days if your written request for change must be made in writing to the receptionist on
duty. 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. 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.

QUESTIONS AND COMPLAINTS?
If you want more information about our privacy practices or have questions or concerns, please
contact us at:
Phone: (713) 941-5760
Email: ahtran@almedavision.com
Mail: Anh H. Tran, OD
10100 Kleckley Dr., #15-B
Houston, TX 77075

If you believe your privacy rights have been violated, you may file a written complaint with the
Secretary of Health and Human Services or to:
HIPAA Privacy
922 W. Walnut
Rogers, AR 72756-3540