HIPAA/PRIVACY PATIENT CONSENT FORM Eyes of the Marina

08/2022

HIPAA/PRIVACY PATIENT CONSENT FORM

Eyes of the Marina Optometry Inc Notice of Privacy Practices provides information about how we may

use and disclose protected health information about you. The notice contains a Patient Rights section

describing your rights under the law. You have the right to review our Notice before signing this Consent.

The term of our Notice may change. If we change our Notice, you may obtain a revised copy by

contacting our office.

By signing this form, you consent to our use and disclosure of protected health information about you for

treatment, payment and health care operations, and/or as required by law. You have the right to revoke

this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have

already made in compliance with your prior Consent. We provide this form to comply with the Health

Insurance Portability and Accountability Act of 1996 (HIPAA).

The doctors and staff of Eyes of the Marina Optometry appreciate your compliance with these policies

and procedures. We strive to provide the best eye care available to you. We are happy to discuss any

questions or concerns you have about these policies.

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Printed Patient Name (and Guardian Name if applicable) Patient or Guardian Signature Date

I give permission to communicate my private healthcare Information to:

_________________________________ _________________________________

Name Relationship

_________________________________ _________________________________

Name Relationship

_________________________________ _________________________________

Name Relationship