I understand Eye Care Specialists P.C.'s policy regarding sharing my protected health information (PHI). I understand that state and federal laws permit Eye Care Specialists P.C. to share information about me, including details of the healthcare services I receive, with family and friends involved in my care or the payment of my healthcare services.
I understand that, per my request, this authorization will permit the named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I understand that I may revoke this authorization at any time by providing written notification to Eye Care Specialists P.C. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that I do not have to sign this authorization in order to receive treatment, payment, or to enroll or be eligible for benefits.
If I do not specify an expiration date or event, this authorization will never expire on which I signed this authorization.
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPAA’s privacy rules after the authorized disclosure.
I also understand that listing individuals below does not grant them direct access to or copies of my medical records. This section is solely for identifying individuals who may contact Eye Care Specialists P.C. to obtain confidential information (PHI) and for your practice to communicate with about my care. Examples of such individuals include a spouse, children, parents, friends, etc.
Per office policy, I understand that I may be charged a $25.00 fee based on the amount of records requested.