Hecker Eye Care Associates HIPAA Compliance Patient Consent Form / AUTHORIZATION TO RECEIVE/RELEASE HEALTH INFORMATION
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature, you have reviewed our notice before signing this consent.
The terms of the notice may change and, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment or healthcare operations.
- Hecker Eye Care Associates reserves the right to change the privacy policy as allowed by law.
- The patient has the right to restrict the use of the information, but Hecker Eye Care Associates does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- Hecker Eye Care Associates may condition receipt of treatment upon execution of this consent.
Please keep in mind that communications via the internet or text are not secure or encrypted. Although it is unlikely, there is a possibility that information you include in any email or text can be intercepted and read by other parties besides the person to whom it is addressed. Please do not include personal identifying information such as your birthdate or personal medical information in any emails or text messages you send to us. We cannot diagnose or treat your condition via the internet or text message; you must come into the office for an appointment.