Thank you for choosing Maine Mall Eye Care as your eye care provider. We ask that you read this form today in order to comply with HIPAA (Health Insurance Portability and Accountability Act). These are rules designed to protect patients' privacy.

It is our policy to release information about our patients only under circumstances relating to either the treatment of the patient or reimbursement for services rendered.

• We may communicate with other doctors regarding your diagnosis or condition, for example, if we refer you to another provider for treatment.

• We will communicate with contact lens manufacturers regarding your prescription if you choose to order contacts through this office.

• If we bill an insurance company for your procedures, we will communicate with them regarding your identification and your diagnosis in order to obtain payment.

• We will attempt to contact you by telephone before your appointment with a reminder call. Please inform us if you would prefer we not identify ourselves as a doctor's office, or if you would prefer us to not leave a message with another person or an answering machine.

• Unless you request otherwise, we will continue sending post cards as a reminder for your annual exams.

• It is our policy to share your information only under these circumstances. Under very specific circumstances we may share information with other individuals.

Please ask a member of our staff if you have any questions.

Thank you.
Maine Mall Eye Care