The purpose of this document is to inform you that we are in compliance with the government’s privacy declaration. It is the policy of this office to obtain a signed patient authorization before making a use or disclosure of protected health information (PHI), except in those circumstances in which HIPAA does not require such an authorization. 

The most common reason why we disclose your health information is for treatment, payment or health care operations (administrative functions). As stated in HIPAA, we will not obtain a signed patient authorization in the following circumstances: 
Setting up an appointment
Testing or examining your eyes
Prescribing glasses or contact lenses or eye medications and faxing them to be filled
Referring you to another doctor or clinic for eye care or low vision aids
Requesting copies of your health information from another provider that you may have seen before us Preparing & sending claims & bills

Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care. We may call or write to remind you of a scheduled appointment or the need for you to make an appointment. Unless you tell us otherwise, we will leave a message with a person or on a machine. This document is a condensed version of our Notice of Privacy Practices. If you would like a more detailed brochure or the full version please ask at the front desk. It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.