Privacy Practices Acknowledgement

I understand that, under the Health Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

• Obtain payment from third-party payers

• Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received River Valley Eye Professionals Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that River Valley Eye Professionals has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that River Valley Eye Professionals restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that River Valley Eye Professionals is not required to agree to my requested restrictions, however, if there is an agreement, then River Valley Eye Professionals is bound to abide by such restrictions.

I understand that I am financially responsible for payment of any services provided, and which are not covered by my insurance, including but not limited to, deductibles and co-insurance.

I request that payment of authorized insurance benefits, including Medicare, be made to River Valley Eye Professionals for any furnished to me by any provider employed or contracted by this office.

I authorize River Valley Eye Professionals to release any medical information about me needed to process claims, determine benefits or the benefits payment for related services to my insurance companies, including insurance company agents or the Center Medicare and Medicaid Services.

This authorization will remain in effect until revoked by me in writing.