CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS EFFECTIVE 01/24/2011
I understand that as part of my health and medical care, Innovative Eyecare, PLLC, originates and maintains medical health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I further understand that this information serves as:
A basis for planning my care and treatment
A means of communication among health professionals who contributes to my care
A means of information for applying my diagnosis and treatment information to my bill
A means for a third-party payer to verify that services were billed as actually provided
And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professions
I further understand and agree that this agreement to release information shall apply to all information accumulated to this date and any information acquired in the future. This agreement to release future information shall remain in force until such time as I shall revoke it in writing.
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. I understand that Innovative Eyecare, PLLC, reserve the right to change their notice and practices. If this notice is revised, I understand that I will be mailed a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that Innovative Eyecare, PLLC is not required to agree to the restrictions requested. I understand that I must revoke this consent in writing, except to the extent that Innovation Eyecare, PLLC has already taken action in reliance thereon.
By Oklahoma law we are required to notify you that the information authorized for release may include records which may include the presence of a communicable or non-communicable or venereal disease, which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).