NOTICE OF PRIVACY PRACTICES:
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information will be used for the following purposes:
- Conducting, planning, and directing my treatment and follow-up care among multiple healthcare providers involved in my treatment.
- Conducting normal healthcare operations, such as quality assessments and audits.
- Obtaining payment from third-party payers.
I have been informed by your organization about the Notice of Privacy Practices, which provides a more detailed description of how my health information may be used and disclosed. By signing this consent form, I confirm that I have had the opportunity to review the Notice of Privacy Practices before providing my consent. I understand that your organization reserves the right to change its Privacy Practices and that I may request an updated copy of the Notice at any time.
I acknowledge that I may request in writing for you to restrict the use and disclosure of my private health information for treatment, payment, or healthcare operations. However, I understand that you are not obligated to agree to such requests unless required by law. If you do agree to any requested restrictions, you are bound to abide by them unless I revoke this consent in writing. Please note that if you have already taken action based on this consent, you are required to continue abiding by the agreed restrictions.
I hereby grant Pupila Family Eye & Ear Care permission to release appropriate medical records to the following individuals:
1. Personal Physician:
3. Family Member: