Patient Privacy Consent Form
Form 4 of 4
Our "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 terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing the form below, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not afffect any disclosures we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Form 4 of 4
Consent to Release Information
By signing this form, I consent for the practice to use and disclose protected health information about me for treatment, payment and health care operations. I permit the practice to release any medical information to the physicians involved in my care. I consent that the practice may call my house or other designated locations and leave a message on voicemail or in person in reference to appointment reminders and patient statements.
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"I have been going to Tennessee Retina for over a year on a monthly basis. I have found this medical facility to be the most organized and efficientl
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