HIPAA Patient Privacy

PRACTICE’S REQUIREMENTS

The Practice:

Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.

Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.

Release of your PHI than that which is provided for under federal law.

Is required to abide by the terms of this Privacy Notice.

Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

Will distribute any revised Privacy Notice to you prior to implementation.

Will not retaliate against you for filing a complaint

AUTHORIZATION FOR TELEPHONE COMUNICATION

Occasionally it is necessary for the staff of Accent Vision Specialists to leave messages for patients. The purpose of these messages may be to notify the patient that the medical staff would like to discuss or schedule testing, or to ask a patient to call regarding an issue or concern. This consent is to authorize discussion of medical conditions or billing either with you or members of your household via phone or voice message. At no time will a representative of Accent Vision Specialists discuss your medical condition without your consent.

Check to authorize discussion of medical conditions/billing with patient over the phone or voice message.

Check to authorize discussion of medical conditions/billing with family member/other representative:

1.)

Relationship:

2.)

Relationship:

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

Printed Patient Name:

First Last

DOB

Patient Signature:

Date