Acknowledgment Of Notice Of Privacy Practice

Acknowledgement of Notice of Privacy Practice

Date of Birth *

Under the Health Insurance Portability and Accountability Act (HIPAA), Arsulowicz Eye Care, the office of Jennifer A. Simon O.D., will use and disclose your protected health information for:

Treatment of your medical condition and maintaining the continuity of your care.
Payment for medical services provided to you.
Routine health care operations including quality assurance, accreditation or educational purposes.

The Notice of Privacy Practices was posted in a clear and prominent location where I was able to view it and a copy was made available for me to keep. If I came in for health care services in an emergency situation, I was able to view the notice as soon as reasonably practicable after the emergency treatment situation

I achnowledge that I received or read the Notice of Privacy Practices for Arsulowicz eye Care, The office of Jennifer A. Simon O.D.

Permitted Use of Protected Health Information.

Protect Health Information *

While you are a patient at Arsulowicz Eye Care, the office Jennifer A. Simon O.D., we may use your protected health information to communicate with the family or friends who are involved with your care. We may also notify your family or freidns of your location and condition in the event of an emergency. You may agree to these uses of your protected health information or you may ask us to limit our use of your protected health information

I agree to the above use of my protected information

Limit Use of Protected Health Information *

If you wish to limit our use of your protected health information please list the people who may be given information about your care, payment arrangements, or location and condition in the event of an emergency.

Please limit the use of my protected health information

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Acknowledgement of Notice of Privacy Practice

Acknowledgement of Notice of Privacy Practice

Date of Birth *

Permitted Use of Protected Health Information.

Protect Health Information *

Limit Use of Protected Health Information *

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