HIPAA Acknowledgment and Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. We have a comprehensive “Notice of Privacy Practices” that describes the use and disclosure of your personal medical information in detail as per federal law. I understand these policies are available upon request.
This notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change and you will be notified at your next visit to review the revised policies and update your
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, I understand that:
• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
• The patient has the right to restrict the uses of their information but the practice does not have to agree to those restrictions.
• The Patient has the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
• The practice may condition receipt of treatment upon execution of this consent.
PATIENT COMMUNICATION – Our policy is to protect the privacy of our patients while ensuring our patients are kept well informed of their appointments and other information. As a service to our patients, we will communicate appointment reminders and other information via text message, email or via phone. Limited information will be left when leaving a voice massage. Medical information will not be shared when leaving a voice message. Please inform our team if you would prefer we use an additional communication preference for appointment reminders or other information related to your care.
CONTACT LENS WEARERS: Contact lenses are medical devices that require additional testing to ensure safety and an accurate prescription. An annual contact lens evaluation is required every year for all contact lens wearers in order to prescribe contacts. The fee for this evaluation is separate from the fee for the routine eye exam and is not refundable. Some vision plans do cover all or part of this fee, while others do not. Any amount not covered by your vision plan is due in full at the time of service.
Dr. Petronack and Associates contracts with most major insurance plans; however I acknowledge that it is my responsibility to confirm health plan coverage and benefits. I understand that I am financially responsible for any balance that is not paid by my insurance company and/ or Medicare. I agree to to pay my balance upon insurance claim processing and my copayments are due on the date of service. I authorize my insurance company benefits and/
or Medicare benefits to be paid directly to Dr. Petronack and Associates and authorize the release of any information required to process my insurance claims.
I have read & agree to the Privacy Act (HIPAA), Advance Beneficiary Notice (ABN) and insurance practices.
By signing this form (whether by original, facsimile, or electronic),I understand I am ultimately responsible for all payment obligations arising out of my treatment or care and guarantee payment for these services. I acknowledge that I have read, understand, and agree to the terms of this agreement.