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  • PLEASE FILL IN THIS FORM ONLY IF YOU ARE A NEW PATIENT OR YOUR INFORMATION HAS CHANGED SINCE YOUR LAST VISIT. OTHERWISE SKIP TO PAGE 2.

     

  • EXCEL EYE CARE OF TEXAS

    CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

     

    Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.


    Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

    We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.


    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone at (817) 806-9848 or by email at reception@exceleyecareoftexas.com.


    Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

  • Date Format: MM slash DD slash YYYY
  • SIGNATURE: I have had full opportunity to read and consider the contents of this Consent and Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

  • Please type your name to sign. (If patient is under 18 years, signature of parent, guardian, or personal representative)
  • INSURANCE (if you are not using insurance, please disregard this section)

  • If you would like for us to bill your medical or vision insurance, please fill out the information below (please note that if your medical insurance does not cover a routine eye examination that the bill may only go toward your deductible, leaving you responsible for the balance).

  • Please provide the primary insured's information below (unless primary insured is also the patient):

  • Date Format: MM slash DD slash YYYY