Arizona Lasik | Patient Privacy Notice
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Patient Privacy Notice

CONSENT FOR PURPOSES OF
TREATMENT, PAYMENT, AND HEALTHCARE OPTIONS

I consent to the use or disclosure of my protected health information by Valley Eye Specialists, Valley Outpatient Surgical Center, and all related entities (the “Practice”) for the purpose of diagnosing or providing treatment to me, obtaining payment for my healthcare bills, or to conduct health care operations. I understand that the diagnosis or treatment of me by the “Practice” may be conditioned upon my consent, as evidenced by my signature on this document.

I understand I have the right to request a restriction, as to how my protected health information is used or disclosed, to carry out treatment, payment, or healthcare operations of the practice. The “Practice” is not required to agree to a restriction that I request. However, if the “Practice” agrees to a restriction that I request, the restriction is binding.

I have the right to revoke this consent, in writing, at any time, except to the extent that the “Practice” has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another healthcare provider, a health plan, my employer, or a healthcare clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review the “Practice’s” Notice of Privacy Practices prior to signing this document. The “Practice’s” Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health information that will occur in my treatment, payment of my bills, or in the performance of healthcare operations of the “Practice.” The Notice of Privacy Practices for the “Practice” is also posted in their office. The Notice of Privacy Practices also describes my rights and the “Practice’s” duties with respect to my protected health information.

The “Practice” reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

First Name *
Last Name *
Email Address *
Date
I have read and
understood this notice:
Yes
No
Signature:
__________________
Signature of Witness:
__________________
Please choose one of the following options:

Please fill out the form above and
mail to our address:

Valley Eye Specialists
Locations

EAST SIDE

 

Mesa Office and Laser Center
160 W. University Drive
Mesa, AZ

Scottsdale Office
Mountainview Center
10585 N. Tatum Boulevard
Suite D-131
Scottsdale, AZ

 

 

WEST SIDE

 

Phoenix Office
2125 W. Indian School Rd.
Phoenix, AZ

Glendale Office
5620 W. Thunderbird
Suite C-5
Gelndale, AZ

 

 

 

 

Please fill out the form above and
click here to send your information to our
practice over the web digitally.

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