Neil P. Schwartz, O.D.

15 Reese Avenue

Newtown Square, PA 19073

610-353-2300

The most common reason why we use or disclose your health information is for treatment, payment or health care operations.

We routinely use your health information inside our office for these purposes without any special permission.

We will not make use of or disclose you health information other than for treatment, payment or health care operations unless you sign a written authorization form.

Unless you tell us otherwise, we will mail an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

The law gives you many rights regarding your health information. You can:

- Ask us to restrict our uses and disclosures for purpose of treatment (except emergency treatment), payment or health care operations.

- Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, or mailing health information to a different address.

- By written request, you can see or get a photocopy of your health information

- Ask us to amend your health information if you think it is incorrect or incomplete.

A full explanation of the privacy practices of this office is posted in the waiting area, or you may request a copy to take with you.

I have read and agree to the privacy practices of the office of Dr. Neil P. Schwartz O.D.

Signature ________________________

Date _______________