Disclosure of Health Information Form

Authorization for Use or Disclosure of Health Information

Our Notice of Privacy provides information about how Capital Eye Consultants may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that, by your signature, you have reviewed our notice before signing this consent. Per HIPAA regulations (Health Insurance Portability and Accountability Act of 1996), you are afforded the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. By signing this form, I understand that: • Protected health information may be disclosed or used for treatment, payment, or healthcare operations. • The practice reserves the right to change the privacy policy as allowed by law. • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.