HIPAA Omnibus Rule

Patient Acknowledgment of Receipt of Notice of Privacy Practices and Consent/Limited Authorization & Release Form

You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION

(This includes your spouse, children, step parents, grandparents and any care takers who can have access to this patient's records):

How do you want to be addressed when called from the reception area?

First Name Only

Proper Surname

Other

Please check your preferred method of communication:

Home Phone

Cell Phone

Text Message

Can we leave automated appointment reminders on your home or cell phone?

Yes

Can we leave messages letting you know your glasses and contacts are ready?

Yes

Do you give our office permission to import your medical history and medications into our electronic medical records system?

Yes

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PROTECTED HEALTH INFORMATION DOCUMENT RELEASE SHOULD I REQUEST MY MEDICAL RECORDS BE SENT TO OTHER ATTENDING DOCTOR/ FACILITYS IN THE FUTURE.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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