Phoenixville Eye Care Specialists HIPAA Statement
Our Notice of Privacy Practices provides information
about how we may use and disclose protected health information about
you. The Notice contains a Patient Rights section describing your
rights under the law. You have the right to review our Notice before
signing this Consent. The terms of our Notice may change. If we
change our Notice, you may obtain a revised copy by contacting our
You have the right to request that we restrict how protected health
information about you is used or disclosed for treatment, payment
or health care operations. We are not required to agree to this
restriction, but if we do, we shall honor that agreement.
By signing our HIPAA form, you
consent to our use and disclosure of protected health information
about you for treatment, payment and health care operations. You
have the right to revoke this Consent, in writing, signed by you.
However, such a revocation shall not affect any disclosures we have
already made in reliance on your prior Consent. This Practice provides
this form to comply with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA).