In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office. The NOTICE OF PRIVACY PRACTICES you have been given describes these uses and disclosures in detail. When you sign this document, you signify that you agree that we can and will use and disclose your health information to TREAT YOU, OBTAIN PAYMENT FOR OUR SERVICES AND TO PERFORM HEALTHCARE OPERATIONS. You also signify that you received a copy of our NOTICE OF PRIVACY PRACTICES. You have the right to ask us to restrict the uses or disclosures made for the purposes of treatment, payment or healthcare operations, but as described in our NOTICE OF PRIVACY PRACTICES, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our NOTICE OF PRIVACY PRACTICES describes how to ask for a restriction. I have read this document and understand it. I consent to the use and disclosure of my health information for the purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES from Catonsville Eye Group.

Effective date of notice: 4/13/2003 - This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. Please review it. General Rules - We respect our legal obligation to keep health info, that identifies you, private. The law obligates us to give you notice of our policies. Generally we can only use health information in our office or disclose it outside of the office, without your consent, for the purposes of treatment, payment or healthcare operations. In most other situations, we will not used or disclose your health information unless you sign a written release. In some situations, the law allows or requires us to disclose your health information without written consent. Use of Disclosures: We use your health information to schedule appts., pretest, prescribe glasses and CL's and bill the insurance companies. In addition, information is disclosed if you are referred to another doctor, choose to get your product outside of our establishment, or need a prescription. We use and disclose your information for healthcare operations in a number of ways. Healthcare operations means those administrative and managerial functions that we must do in order to run our office. We may call, txt or email you to confirm appts, our product delivery. Uses Without Authorization: In limited situations the law allows us to disclose your information. Disclosures for law enforcement purposes, workers compensations programs, are among the examples. Other Disclosures: We will not make any other uses or disclosures of your health information unless you sign a written auth form. Your Rights: The law gives you the right to: ask us to restrict our uses for purposes of treatment, payment and billing. To ask for a restriction, a written request must be submitted to our Privacy Officer. You can ask us to communicate with you in a confidential manner. We will accommodate when possible. You can ask to see or get photocopies of your health info. You can ask to amend your health info if you feel it is incorrect or incomplete. Our Notice of Privacy Practices: By Law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with the law. If we change, the chances will affect all of your health info. If we change we will post those changes in our office. Complaints: If you think that we have not properly respected the privacy of your health info., you are free to complain to us or to the US DHHS, Office of Civil rights. We will not retaliate against you. If you complain to us, send a written complaint to our Privacy Officer, if you prefer, you can discuss your complaint in person or by phone. For More Information: If you want more information about or privacy practices, call Lauren Caplan, Privacy Office, at our office.