Rogers 763.428.3757  |  St. Michael 763.497.3754  |

Rogers 763.428.3757 | St. Michael 763.497.3754

Notice of Privacy Practices-Patient Summary

Dr. Leah Colby, O.D.
Dr. Erin Dunphy, O.D.
Dr. Gina Gill, O.D.
Dr. Chris Roghair, O.D.

EyeWest Vision Clinic and Optical
13900 Northdale Blvd. Rogers, MN 55374 P: 763-428-3757 F: 763-428-9820
1 Central Ave. West #104, St. Michael, MN 55376 P: 763-497-3754 F: 763-497-3811

This summary discloses how health information about you may be used. A full notice of your privacy rights has also been made available to you.

EyeWest Vision Clinic and Optical uses health information about you for treatment, to obtain payment for treatment with your authorization as required, for administrative purposes, and to evaluate the quality of care you receive.

EyeWest Vision Clinic and Optical will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

EyeWest Vision Clinic and Optical may use your information to provide appointment reminders, information about treatment alternatives or other health-related issues.

EyeWest Vision Clinic and Optical may disclose your information for public health activities, to funeral directors to enable them to carry out their activities, for organ and tissue donations, research, health and safety, and governmental function in order to comply with workers compensation laws and regulations. You have the right to request restriction, report and retain a copy of your health record, request communication of your information by alternative means at alternative locations, revoke your authorization and request an account of your health records.

You may contact our Clinic Manager and/or the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

EyeWest Vision Clinic and Optical must maintain the privacy of protected health information, provide you with notice of its legal duties and privacy practices with respect to your health information, abide by the terms of the notice, notify you if it was unable to agree to the requested restriction on how your information is used or disclosed, accommodate reasonable requests you may make to communicate with health information by alternative means or by alternative locations and obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

If you have any questions or complaints, please contact our Clinic Manager at 763.428.3757 Rogers clinic or 763.497.3754 St. Michael Clinic.

Effective 7/1/2018