somerseyecenter.com - HIPAA Compliance

HIPAA COMPLIANCE AUTHORIZATION

FOR USE OR DISCLOSURE OF HEALTH CARE INFORMATION
PATIENT NAME
DATE OF BIRTH

MonthDayYear
Date
By signing this form I authorize the use and disclosure of my health information as described in the Notice of Privacy Practices. I have been given a copy of the Notice of Privacy Practices to read and keep if I desire.

To revoke this authorization, I must do so in writing and send to:

SOMERS EYE CENTER
Attention: HIPAA Compliance Officer
2790 Clay Edwards Dr. Ste 1240
North Kansas City, MO 64116

I understand that it is possible that information used or disclosed with my permission may be re disclosed by the recipient and is no longer protected by the federal Privacy Standards.
Speak directly to me (Do not give information to anyone else).May leave a message.May disclose information to the following person(s):
May leave a message. PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
May disclose information to the following person(s):
PATIENT SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

HIPAA COMPLIANCE AUTHORIZATION