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Our Notice of
Privacy Practices provides information about how we may use and disclose
protected health information about you. The Notice contains a Patient Rights
section describing your rights under the law. You have the right to review our
Notice before signing this Consent. The terms of our Notice may change. If
we change our Notice, you may obtain a revised copy by contacting our office.
You have the right
to request that we restrict how protected health information about you is used
or disclosed for treatment, payment or health care operations. We are not
required to agree to this restriction, but if we do, we shall honor that
agreement.
By signing this
form, you consent to our use and disclosure of protected health
information about you for treatment, payment and health care operations.
You have the right to revoke this Consent, in writing, signed by you. However,
such a revocation shall not affect any disclosures we have already made in
reliance on your prior Consent. The Practice provides this form to comply with
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The
patient understands that:
Protected health information may be disclosed or used
for treatment,
payment or health care operations.
Cochise Eye and Laser has a Notice of Privacy Practices
and that the
patient has the opportunity to
review this Notice.
Cochise Eye and Laser reserves the right to change the
Notice of Privacy
Practices.
The patient has the right to restrict the uses of their
information but
Cochise Eye and Laser does not have
to agree to those restrictions.
The patient may revoke this Consent in writing at any
time and all future
disclosures will then cease.
Cochise Eye and Laser may condition treatment upon the
execution of
this Consent.
Signature:_____________________________________
Patient or Legal Guardian
Patient Name (please print):_____________________________________
Date:_____________
CE&L Witness:_____________________________________
[ ] Patient prefers not to sign.
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