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Notice of Privacy Practices

Effective Date of Notice: April 14, 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.


In normal operations we must use your personal health information (PHI). This policy describes how information about you may be used and disclosed and how you can gain access to this information. We respect our legal obligation to keep PHI that identifies you private. We are obligated by law to give you a notice of our privacy practices.

Contact Person

Dr. Jeremy Elmore
1634 West Smith Valley Road Suite A
Greenwood, IN 46142
317-883-2020 phone


  • Treatment, Payment and Health Care Operations

The most common reason why we use or disclose your health information is for treatment, payment and health care operations. We routinely use your health information inside our office for treatment, payment and health care operations without any special permission. Examples of these uses include: setting appointments, examining your eyes, prescribing glasses and contact lenses and medications, referring you to a specialist, billing your insurance and internal quality assurance. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission. For most all other types of disclosure, we are required to obtain your permission.

  • Uses and Disclosure for Other Reasons Without Permission

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us. Such disclosures are:

  • When a state of federal law mandates that certain health information be reported for a specific purpose;
  • For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the FDA regarding drugs or medical devices;
  • Disclosure to governmental authorities about victims of suspected abuse, neglect or domestic violence;
  • Uses and disclosure for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; of for investigation of possible violations of health care laws;
  • Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • Disclosure for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations than handle organ or tissue donations;
  • Uses and disclosures for health related research;
  • Uses and disclosures to prevent a serious threat to health or safety;
  • Uses or disclosures for specialized government functions, such as for protection of the president or high ranking governmental officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • Disclosures relating to worker’s compensation programs;
  • Disclosures to “business associates” who perform health care operations for us and who agree to keep your health information private
  • Appointment Reminders

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you.

  • Other Uses and Disclosures

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form”. The content of an “authorization form” is determined by federal law. If we initiate the process and ask you to sign an “authorization form”, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign the authorization, you may revoke it in writing at any time unless we have already acted in reliance upon it.

  • Your Rights Regarding Your Health Information

The law gives you many rights regarding your health information. You can:

  • Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person listed at the beginning of this Notice.
  • Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E-mail to your personal E-mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person listed at the beginning of this Notice.
  • Ask us to see or to get photocopies of your health information. You will be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off-site). You may have to pay for photocopies in advance. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person listed at the beginning of this Notice.
  • Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the correct information to the persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if you notify you in writing of the extension. If you want to ask us to amend your health information, send a written request to the office contact person listed at the beginning of this Notice.
  • Get a list of the disclosures that we have made of your health information within the past 6 years (or shorter period if you specify). By law, the list will not include disclosures for purposes of treatment, payment or health care operations and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person listed at the beginning of this Notice.
  • Get additional paper copies of this Notice of Private Practices upon request. It does not matter whether you got one electronically of in paper form already. If you want additional paper copies, send a written request to the office contact person listed at the beginning of this policy.
  • Our Notice of Private Practices

By law, we must abide by the terms of this Notice of Private Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Private Practices, we will post the new Notice in our office and have copies available in our office.

  • Complaints

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person listed at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

  • For More Information

If you want more information about our privacy practices, call or visit the office contact person listed at the beginning of this Notice.