CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Our Privacy Pledge
We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your protected health information.
There are several circumstances in which we may have to use or disclose your protected health care information.
- We may have to disclose your protected health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
- We may have to disclose your protected health information and billing records to another party if they are potentially responsible for the payment of your services.
- We may need to use your protected health information within our practice for quality control or other operational purposes.
If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail.
By signing this form, you are giving our office authorization to release any necessary medical information to process your insurance or Medicare claims, as well as authorizing our office to receive payment of medical benefits for services or supplies provided by Penelope S. Suter, OD or associates.
Your Right To Limit Uses Or Disclosures
You have the right to request that we do not disclose your protected health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree with your restrictions. However, if we agree with your restrictions, the restriction is binding on us.
Your Right To Revoke Your Authorization
You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your protected health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your protected health information if they decide to contest any of your claims.
APPOINTMENT/OPTICAL REMINDERS, HEALTH CARE
AND BILLING INFORMATION AUTHORIZATION
Your optometrist and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you with appointment or optical reminders, billing information, or health care related information that may be of interest to you. By signing this form, you are giving us authorization to contact you with these reminders and information. This contact may be by way of mail or phone. If this contact is made by phone and you are not home, a message will be left on your answering machine. If the contact phone number you have provided us with is your business phone, a message will be left on your voicemail or our name and phone number only will be left with the receptionist.
You may restrict the individuals or organizations to which your protected health care information is released or you may revoke your authorization to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by federal privacy rules.
You have the right to refuse to give us this authorization. If you do not give us authorization it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect the information that we use to contact you to provide appointment or optical reminders, billing information, or any health care related information at any time.
This notice is effective as of 8/1/2003. This authorization will expire seven years after the date on which you last received services from us.
I authorize you to use or disclose my protected health information in the manner described above. I am also acknowledging that I have received a copy of this authorization.