Scenic Eye Care Patient HIPAA Acknowledgment and Designation Disclosure Form

I. Acknowledgment of Practice's Notice of Privacy Practices:

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms.

Click Here to view our Notice of Privacy Practices

Name*

First Last

Birthdate*

Signature of Patient/Parent/Guardian

Date

II. Designation of Certain Relatives, Close Friends, and other Caregivers as my Personal Representative:

I agree that the practice may disclose certain pieces of my health information to a Personal Representative of my choosing, since such person is involved with my healthcare or payment relating to my healthcare. In that case the Physician Practice will disclose only information that is directly relevant to the person's involvement with my healthcare or payment relating to my healthcare.

Print Name:

Last four digits of SSN or other identifier:

Print Name:

Last four digits of SSN or other identifier:

Print Name:

Last four digits of SSN or other identifier:

III. Request to Receive Confidential Communications by Alternative Means:

As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by the alternative means that I have listed below.

Home Telephone Number:

Okay to leave message with detailed information
Leave message with call back numbers only

Work Telephone Number:

Okay to leave message with detailed information
Leave message with call back numbers only

Written Communication Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Okay to mail to address listed above

Email me at:

Other:

IV: The following person(s) are NOT AUTHORIZED to receive my Patient Health Information (PHI):

Name(s):

V. The HIPAA Privacy rule requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI.

I understand that this accounting will not reflect disclosures that are made in the course of the Practice's ordinary health care activities related to providing patient treatment, obtaining payment for its services, or its internal operations. Also, the Practice does not have to account for disclosures for which I have executed an Authorization permitting disclosures of my PHI.

Date of Disclosure Request

Disclosed to whom: Address/Fax

Description of disclosure

Purpose of disclosure

Dates of Service of disclosure

Person completing request

Date completed