With my consent, EyeCare Professionals, P.A. may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to EyeCare Professionals, P.A. Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. EyeCare Professionals, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to EyeCare Professionals, P.A.'s Privacy Officeer at 1501 Lakeland Drive, Suite 100, Jackson Mississippi 39216.
With my consent, EyeCare Professionals, P.A., may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, optical goods ordered, and any call pertaining to my clinical care, including laboratory results among others.
With my consent, EyeCare Professionals, P.A. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, and patient statements, as long as they are marked personal and confidential.
With my consent, EyeCare Professionals, P.A. may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that EyeCare Professionals, P.A. restrict how it uses or discloses my PHI to carry out TPO.
However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to EyeCare Professionals, P.A.'s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent taht the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, EyeCare Professionals, P.A. may decline to provide treatment to me.