Patient Privacy Informed Consent (HIPAA)

s. My medical information will only be
released to other medical providers for continuity of care and insurance companies in
order to get my medical claims reimbursed. Examples of medical providers may include
but are not limited to: Eye Lasik Of Austin, M.D., Clinical Pathology Associates, Texas
Oculoplastics, and Austin Retina Associates. Any insurance company or companies
involved in the reimbursement of my medical/routine vision care will be based on all the
insurance information I provide. I do understand that my patient information and
diagnosis will be forwarded to these entities to facilitate continuity of care, and to get
claims paid. River Place Vision Center practices a minimum information disclosure
policy, and only necessary information will be forwarded to these entities.