CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

I understand that as part of my healthcare, Larimore, Baker, Brown and Associates, Inc., dba Sunshine Eye clinic originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, billing information and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment
• A means of communication among the many health professionals who contribute to my care
• A source of information for applying my diagnosis information to my bill
• A means by which a third party payer can verify that services billed were actually provided
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
• A means by which payment for services can be made and
• A means by which we may communicate to you by mail when you have materials ready for pick up

I understand and have been provided with a NOTICES OF INFORMATION PRACTICES that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change its notice and practices and will provide a copy of any revised notice. I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

I have the right to request restrictions on the use of my health information. I understand that my request is not agreed to by Larimore, Baker, Brown and Associates, Inc., dba Sunshine Eye Clinic, unless Sunshine Eye Clinic agrees to the request in writing.

By clicking submit below I agree and understand that for convenience or necessity I would like my health information available to the following friends or family members:

While the filing of Insurance claims is a courtesy that we extend to our patients, all charges are your responsibility.

Acknowledgement of Financial Responsibility:

By submitting this information I certify that all information is correct and I realize that if the account is not paid all collection fees, attorney fees, and court costs incurred to collect the balance of the account also becomes my responsibility.

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