The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you have received
in our office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice serves to inform you that we have a policy regarding the ways in which we may use and share medical information about
you. This policy includes a description of your rights and certain duties that we have regarding the use and disclosure of medical information.
OUR LEGAL DUTY:
keep your medical information private
- To make this notice available which describes our legal duties, privacy practices, and your rights regarding your medical information
- To follow the terms of the notice that is now in effect
WE HAVE THE RIGHT TO:
- Change our privacy policies and the terms of this notice at any time, provided that the changes are permitted by law
- Make the changes in our privacy policies and the new terms of our notice effective for all medical
information that we keep, including information previously created or received before the changes.
NOTICE OF CHANGES TO PRIVACY POLICIES:
- Before we make an important change to our privacy policies, we will change this notice and
make the new notice available upon request
I understand that this serves only as an overview and a more detailed policy is available for my review upon my request
I do hereby give my permission to Bannett Eye Centers, P.A. to release some confidential medical information such as appointments, test results, medical prescriptions,
refills and instructions, referral information, and billing questions to my immediate family members or other concerned individuals involved in my health care. All other medical information will not be discussed without my express permission. Information
may be conveyed by phone, fax, or in person.
PERMISSION TO LEAVE MESSAGES ON YOUR ANSWERING MACHINE:
YES _____ NO_____