Medical And Vision Insurance Information Form (Page 2 of 4) in pdf

Tuscaloosa Ophthalmology, P.C. ♦ A. George Kudirka, MD ♦ E. Van Johnson, MD

HIPAA AMENDMENTS

PERMISSION TO RELEASE/RESTRICT VERBAL/WRITTEN HEALTHCARE INFORMATION

I authorize TUSCALOOSA OPHTHALMOLOGY, P.C. and medical staff members to discuss my medical history,

diagnosis, treatment and prognosis with those listed by name below. I understand this may include information

regarding testing, examination and treatment for HIV, AIDS related illness, mental health and drug, alcohol or

chemical abuse.

I understand that by leaving all spaces blank I am indicating my choice to be a “No Information” patient, and I do not

want any information released to anyone else.

______________________________________ ______________________________________

_______________________________________ _____________________________________

_____________________________

______________________________________

PATIENT’S NAME PRINTED

AUTHORIZED SIGNATURE

_________________________

__________________________

RELATIONSHIP TO PATIENT

DATE

PATIENT CONSENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to

privacy regarding my protected health information. I understand that this information can and will be used to:

•

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be

involved in that treatment directly and indirectly.

•

Obtain payment from third-party payers.

•

Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and

disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to

signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time

to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of

Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out

treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions,

but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying

on this consent.

_______________________________

________________________

(

)

PATIENT NAME

PRINTED

DATE

____________________________________

__________________________________

PATIENT/AUTHORIZED SIGNATURE

RELATIONSHIP TO PATIENT

Medical And Vision Insurance Information Form Page 2

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