By signing this form I authorize the use and discloser of my health information as described in the Notices of Privacy Practices. I have been given a copy of the Notice of Privacy Practices to read and keep if I desire.
To revoke this authorization, I must do so in writing and send to Somers Eye Center, Attention: HIPPA Compliance Officer, 2790 Clay Edwards Dr. Ste 1240, North Kansas City, Mo. 64116. I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the federal Privacy Standards.