Patient Privacy Informed Consent (HIPAA)

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I have been informed, and I consent to the release of my medical information, in compliance with federal HIPAA regulations.

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.

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I understand that River Place Vision Center reserves the right to change their privacy notice and make changes effective for all personal health information they may already have concerning me. If any changes occur, River Place Vision Center has agreed to provide me with a revised copy upon my request.

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I authorize River Place Vision Center and Dennis Smith, O.D., and his staff to release my health information for these purposes.

Name

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Patient or Guardian Signature

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