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.