Privacy Practice Form

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review this notice carefully and acknowledge receipt and consent by signing below.

If you have any questions about this Notice please contact Steve Mondok, Privacy Officer.

This Notice describes how Handel Vision Clinic may use and disclose your (or your child’s) protected health information. The terms of this Notice of Privacy Practices are effective April 14, 2003, and remain in effect until we revoke it. This office will share health information as necessary to provide health care and receive reimbursement for those services as permitted by law. This office is required by law to maintain the privacy of our patient’s health information and to provide patients with this Notice of Privacy Practices. It is implied by the patient (or patient’s representative) that any person(s) present in the examination room is entitled to hear the discussion between the doctor and the patient. This office will abide by the terms of this Notice of Privacy Practices as necessary. A copy of any revised notices will be available in this office, or, upon request a copy may be mailed to your address maintained on file.


  • Treatment, Payment, and Health Care Operations

  • Appointment Reminders

  • Treatment Alternatives

  • Health-Related Benefits and Services

  • Individuals involved in your healthcare

  • Abuse and Neglect

  • As required by law

  • To avert a serious threat to health or safety

  • Research

  • Communication with family and friends

  • Business Associates

  • Special Situations:

  • Military or Veterans

  • Worker’s Compensation

  • Public Health Risks

  • Health Oversite Activities

  • Judicial/Administrative Proceedings

  • Law Enforcement

  • Coroners, Medical Examiners, and Funeral Directors

  • Correctional Institutions


  • You have the right to confidential communication of your personal health information.

  • You have the right to request restrictions on the use and disclosure of your health information.

  • You have the right to inspect and retain a copy of your health information.

  • You have the right to ask for an amendment to your health information if you believe it is incorrect or incomplete.

  • You have the right to file a written complaint if you believe your rights have been violated.

  • You have the right to an adequate Notice of Privacy Practices.

If you believe your privacy rights have been violated, you may file a written complaint with Steve Mondok, Privacy Officer, at 115 West Broad Street Newton Falls, Ohio 44444. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. in writing. There will be no retaliation for filing a complaint. We reserve the right to revise or amend this Notice of Privacy Practices.

​​​​​​​I consent to receive TEXT and/or E-MAIL reminders and other communications/information at the phone number and /or E-MAIL address provided to this practice.

Signature of patient responsible party :