Golden Eye Surgeons and Consultants

TO OUR PATIENTS: We are required by Federal Law entitled “Health Insurance Portability and
Accountability Act” to present you with the following form for your review and signature:

With patient consent, Golden Eye Surgeons and Consultants may use and disclose protected health information to
carry out treatment, payment, and healthcare operations only. This includes, but is not limited to:

• appointment reminder calls to your home
• mailing information to your home regarding our practice
• calling and faxing prescription authorization to your pharmacist

Certain practices are NOT approved uses for your protected health information and will not ever be performed.
This includes:

• Selling your information to any third parties for marketing purposes
• releasing your information for any purposes without your signed consent

To help us protect your health information, we will maintain a copy of your driver’s license or state identification
card with your signature on file. If you wish, you do have the right to review the Notice of Privacy Practices prior
to signing this consent. You will likely be seeing this notice, or ones similar to it, at other health care facilities.
Golden Eye Surgeons and Consultants reserves the right to revise its Notice of Privacy Practices at any time,
within the parameters of HIPAA. A revised Notice of Privacy Practices may be obtained by sending a written
request to the Golden Eye Surgeons and Consultants Privacy Officer.

You have the right to review your medical records and make amendments to those records. Records may be
obtained by sending a written request to the Golden Eye Surgeons and Consultants Privacy Officer.

You have the right to submit a written request that Golden Eye Surgeons and Consultants restricts how it uses or
discloses your protected health information.

You may revoke this consent in writing except to the extent that the practice has already made disclosures with
this prior consent.

Please circle:

Yes	NO	Golden Eye Surgeons and Consultants may call my home, or another designated number and leave a message, recorded or with a person, regarding items that assist the practice in carrying out treatment, payment, and operations.
Yes	NO	Golden Eye Surgeons and Consultants may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment, and operations.
Yes	NO	Golden Eye Surgeons and Consultants may email to my home or other designated location any items that assist the practice in carrying out treatment, payment, and operations.
Yes	NO	Golden Eye Surgeons and Consultants may text message my cellular phone with any information that assists the practice in carrying out treatment, payment, and operations.

Patient Name Date of Birth

Signature____________________________________ Date