Authorization to release medical information:
I authorize the release of medical information regarding myself /my dependents and my current condition to my referring physicians.
Notice of Privacy Practices – Acknowledgement:
We keep a record of the health care services we provide to you. You may request a copy of your medical record in writing. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. You may request a copy of your record or get more information by contacting Clarity Vision Care. Our notice of privacy practices is available at the reception desk. We will be happy to provide you with a copy per your request. I acknowledge the notice of privacy practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.