Brad Coers, O.D., P.C. Phone: 812-418-0080 Fax: 812-418-0090 2520 California St. Suite G Columbus, IN 47201 Office Contact: Teresa Moody

Effective Date of Notice: 4/14/03 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect you health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining you eyes; prescribing glasses; or eye medications and faxing them to be filled; referring you to another doctor or clinic for eyecare or services; or getting copies of your health information from another professional that you have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking about your vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts. "Health care operations" means those administrative and managerial functions that we have to do in order to run our internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at all. Such uses or disclosures are: When a state or federal law mandates that certain health information be reported for specific purpose; for public purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Federal Food and Drug Administration regarding drugs or medical devices; Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; Disclosures for judicial and administrative proceeding, such as in response to subpoenas or orders of courts or administrative agencies; Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; Uses and disclosures for health related research; Uses and disclosures to prevent a serious threat to health or safety; Uses and disclosures for specialized governmental functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; Disclosures of de-identified information Disclosures relating to worker's compensation programs; Disclosures of a" limited data set" for research, public health, or health operations; Incidental disclosures that are an unavoidable by product-of permitted uses or disclosures; Disclosures to "business associates" who perform healthcare operations for us and who commit to respect the privacy of your health information; Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care. APPOINTMENT REMINDERS

. We may call or write to remind your scheduled appointment, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you 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. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is to determined by federal law. Sometimes we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you don't have to sign it. If you don't sign the authorization, we can't make the use or disclosure. If you do sign, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of the Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can: Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatments), payment or health care operations. We don't have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. 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. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send us a written request to the office contact person at the address or fax at the beginning of this Notice. Ask to see or get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking (or 60 days if information is stored off­site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send us a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask us to amend your health information if you think that it is incorrect or incomplete. Ifwe agree, we will amend the information within 60 days from the date you asked us. We will send the corrected information to the persons who we know got the wrong information, and others that you specify. If we don't agree, you can write a statement of your position, and we will include it with your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend you health information, send a written request, including your reasons for the statement, to the office contact person at the address or fax at the beginning of this Notice. Get a list of the disclosures that we have made of your health information within the past six years (or shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year with out charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days or receiving it, but by law we can only have one thirty day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. . Get additional copies of this Notice upon request whether electronically or paper form. If you want additional copies, send a written request to office contact person at the address or fax at the beginning of this Notice. OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice until we choose to change it. We reserve the right to change this Notice at any time as allowed by law. Ifwe change this Notice, the new will apply to your health information we already have and future information we might obtain. COMPLAINTS AND FOR MORE INFORMATION Complaints can be made to the U.S. Department of Health and Human Services, or Office of Civil Rights. Or send a written complaint to this office's contact person found at the beginning of this Notice. . . . .h HIPAA.