Health Insurance Portability Accountability Act Acknowledgement
I understand that as part of my health care, Kent Eye Clinic originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnosis, treatment, and any plans for future care of treatment. I understand that this information serves as:
- A basis for planning my care and treatment
- A means of communication among the many health professionals who contribute to my care
- A source of information for applying my diagnosis and treatment information to my bill
- A means by which a third-party payer can verify that services billed were actually provided
I understand that I have the following rights and privileges per the Notice of Privacy Practices (this document is available upon request):
- The right to review the notice prior to signing this consent
- The right to object to the use of my health information for directory purposes
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
I understand that Kent Eye Clinic is not required to agree to this restrictions requested. I understand that I may revoke this consent in writing, except to the extent, that the origination has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Kent Eye Clinic reserves the right to change their notice and practices, and prior to implementations, in accordance with Section 164.520 of the Code of Federal Regulations. Should Kent Eye Clinic change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. Mail or, if I agree, email).
I wish to have the following restrictions to the use or disclosures of my health information: _____________________________________________________________
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosures for these permitted uses including disclosures via fax.