Bay Area Eye Center - HIPAA Patient Disclosure Information

Bay Area Eye Center
Bruce Cline OD | Shannon LeBus OD

Patient Disclosure Instructions

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

Patient Name*

Patient Date of Birth

Date

Patient Email

To recieve a confirmation of your submission

I wish to be contacted in the following manner (check all that apply)

Cell Phone

Area CodePhone Number

Select all the applies

Written CommunicationOK to leave message with detailed informationOK to mail to my home AddressLeave message with call-back number only

Home Phone

Area CodePhone Number

Select all the applies

OK to leave message with detailed informationLeave message with call-back number only

Work Phone

Area CodePhone Number

Select all the applies

OK to leave message with detailed informationLeave message with call-back number only

I allow Bay Area Eye Center to give my clinical information to or answer question(s) from.

Spouse

Enter Name

Parent

Enter Name

Child

Enter Name

Other(specify)

Enter Name or Details

I acknowledge that I have been provided the opportunity to read a copy of
Bay Area Eye Centers Notice of Privacy Practices.

Patient/Guardian Signature*

Date

A communication barrier prevented BAEC from obtaining acknowledgment.

STAFF INITIAL

An emergency situation prevented BAEC from obtaining acknowledgment.

STAFF INITIAL

Individual refused to sign form.

STAF INITIAL

Other