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.

All EyeSight MD physicians, staff members, volunteers, as well as any business associates or partners with whom we share your health information will follow the practices as outlined in this notice.

 

What is protected health information?

Protected health information is any health information that identifies you, such as your name, date of birth and Social Security number.  We keep record of services our patients receive in order to provide the best possible care.  We maintain strict adherence to state and federal laws when working with patient information.

 

Explanation of your rights regarding your personal health information

In most cases, you as the patient have the right to:  View and copy your health and billing records; Amend your health record, if you believe it is inaccurate or missing important information; Ask for an accounting of times, if any, when we have disclosed your health information for reasons other than for treatment, payment of health care operations; Request certain restrictions on how we use and/or disclose your health information.  We will notify you if we are unable to comply with your request; Specify the manner in which we communicate with you in order to keep your information confidential, for example, communicate via e-mail or call you at a specified number.

 

To exercise any of these rights, simply submit a written request to:

Privacy Officer, 392 S. Glassell St. Suite 100, Orange, CA 92866

*Please note, a fee may be charged for the costs associated with copying, mailing, or other related expenses that we incur.

 

If you have received an electronic copy of this notice, we will provide you with a paper copy upon request.  Changes to this notice may occur at any time and can apply to medical information we already hold as well as new information after the change occurs.  Prior to any significant policy changes, we will post the notice in our office.

 

If you believe that your privacy rights have been violated, you may file a complaint with our Privacy Officer by calling (714) 289-2389 or by writing to:  Privacy Officer, 392 S. Glassell St. Suite 100, Orange, CA 92866.  You may also file a complaint with the Secretary of Health and Human Services.  You will not be retaliated against for filing a complaint.

 

How is your health information used?

For Treatment – Sending your medical information to a referring physician. 

For Payment – To assure services are billed accurately to patients, insurance companies, Medicare and/or third parties. 

For Health Care Operations – Conducting quality assessments.

 

Your health information may also be used in other instances, such as:  Public health risks/purposes; Participating in health oversight audits and/or inspections; Cooperating in judicial and administrative proceedings; Government health data systems; Participation in research studies; Radiology Accreditation Centers, such as the American College of Radiology; Assisting medical examiners; Worker’s compensation purposes; In case of an emergency; In cases required by law.

 

We may contact you in regard to:  Appointment reminders, prescriptions, scheduling and rescheduling; Treatment options and alternatives; Health related information and benefits that may be of interest to you.

 

SMS opt-in or phone numbers for the purpose of SMS are not shared with any third parties or affiliate companies for marketing purposes.

□ By checking this box, I agree to receive text messages from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami) at the phone number provided. The SMS frequency may vary. Data rates may apply. Text HELP to 714-289-2389 for assistance. Reply STOP to opt out of receiving SMS messages from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami). If you opt out, you will receive no further SMS communication or appointment courtesy reminder.  

SMS CONSENT: The information (714-289-2389, 714-497-0967 and 714-462-3693) obtained as part of the SMS consent process will not be shared with third parties for marketing purposes.

 

Types of SMS Communications

Upon consenting to receive text messages from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami) we may contact you in regard to:  appointment reminders, prescriptions, scheduling and rescheduling; Treatment options and alternatives; Health related information and benefits that may be of interest to you.

 

Message Frequency

Our SMS message frequency is estimated to be 1 to 2 messages for every upcoming appointment.

 

Potential Fees for SMS Messaging

Carriers may charge fees for each message sent or received. These fees can vary based on the carrier's pricing structure and whether the message is sent domestically or internationally.

 

Opt-In Method

Patients may opt-in for SMS messaging from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami) verbally during a call made to our office. During the call, patients will be asked: "Do you agree to receive texts from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami). Message frequency varies. Message and data rates may apply. Text HELP for help, text STOP to opt-out. This consent agreement will not be shared with third parties and affiliates for marketing purposes. No SMS communication will be initiated without patient consent.

 

Opt-out Method

Patients can opt-out of SMS messaging from Samida Medical Group, Inc. (DBA EyeSight MD office of Dr. David Sami) by replying STOP at any time to any received SMS message. Once opted out, you will receive no further SMS communication. Which also means you will no longer receive an appointment courtesy reminder. Patients can opt back in at any time by replying START.

 

Standard Messaging Disclosures

  • Messaging frequency may vary.

  • Message and data rates may apply.

  • To opt out at any time, text STOP.

  • For assistance, text HELP or visit our website at www.eyesightmd.com

Unless the disclosure is for treatment, payment, and/or healthcare operations, or a disclosure is required by law, we will obtain your written authorization before disclosing your health information.  You may revoke your authorization at any time.

By signing below, I acknowledge that I have received EyeSight MD’s Notice of Privacy Practices.  I understand that I may ask questions about the Notice of Privacy Practices at any time.