Target Optical HIPPA notice and Insurance

Person getting their exam today (legal name)

First Last

Patient's DOB

Gender

Male
Female

Home Address

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

Phone

Email

Are you using insurance today?

YES
NO

(if yes, please fill out information below)

Name of primary card holder for the insurance

First Last

Primary DOB

Gender

Male
Female

This person's relation to today's patient

Employer

Insurance Name

Group Name or # (if listed on card)

Member ID # (if listed on card)

Last 4 of primary card holder's SS

Acknowledgement of Receipt of Privacy Notice

By signing this acknowledgement of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below (available online at www.JohnRileyOD.com).

I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by the Location (for example: mailing of exam reminders or information about services provided by the Location).

I can be assured that this Location does not sell my personal health information of any kind to a third party for such party's own use. I acknowledge and agree that the Location may submit my vision benefit claims to my health plan to receive reimbursement directly for the services and products that I have received from the Location.

Patient Signature or Patient's Legal Representative

AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize as a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.

1. Persons/Organizations authorized to use or disclose the information: Office of Dr. John A Riley, OD
2. Persons/Organizations authorized to receive the information: Target Optical
3. Specific description of information that may be used/disclosed: My name, address, telephone number, email address, and next appointment date(s) and time(s).
4. As part of our recall program, the information will be used/disclosed for the following purposes:
a) For the purpose of providing Target Optical coupons and service and product information either from this office or directly from Target Optical; and
b) To compare mailing lists with Target Optical to help avoid duplicate mailings
5. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment or eligibility for benefits unless allowed by law.
6. The organization authorized to use/disclose the information will receive compensation for doing so: No
7. I understand that I may inspect or copy the information used or disclosed.
8. I understand that I may revoke this authorization at any time by notifying the person/organization providing the information in writing except to the extent that: a) action has been taken in reliance on this authorization; or b) if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.
9. This authorization expires four years from the date of my signature.

Patient Signature or Patient's Legal Representative

Date
Date Format: MM slash DD slash YYYY