Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights Section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of your Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or healthcare operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: • Protected health information may be disclosed or used for treatment, payment, or healthcare operations. • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. • The Practice reserves the right to change the Notice of Privacy Practices. • The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. • The patient has the right to request restricted release of PHI to a healthcare plan if the patient pays in full. • The patient may revoke this Consent in writing at any time and all future disclosures will then cease. • The Practice may condition receipt of treatment upon the execution of this Consent.
By reading and signing this form I accept my rights and responsibilities as a patient and consent to the treatment and services provided by Idaho Eye Center. I authorize the release of any medical information necessary to process the bill to my insurance company and request payment of benefits to Idaho Eye and Laser Center. I acknowledge that I am financially responsible for payment whether or not covered by insurance. I acknowledge that this authorization has no expiration date and is valid until revoked.