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.