somerseyecenter.com - HIPAA Compliance

HIPAA COMPLIANCE AUTHORIZATION

FOR USE OR DISCLOSURE OF HEALTH CARE INFORMATION
PATIENT NAME
DATE OF BIRTH

MonthDayYear
Date
By signing this form I authorize the use and disclosure of my health information as described in the Notice 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: HIPAA 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 re disclosed by the recipient and is no longer protected by the federal Privacy Standards.
I authorize Somers Eye Center to:

Speak directly to me (Do not give information to anyone else).May leave a message.May disclose information to the following person(s):
May leave a message. PHONE NUMBER:
Please enter a valid phone number.
May disclose information to the following person(s):
PATIENT SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

HIPAA COMPLIANCE AUTHORIZATION