Name: Brooks Eye Center
Address: 3545 Bluecutt Road, Columbus, MS, 39705, US
Telephone: 662-327-2020
Price range: $000 - $300

Our Notice of Privacy Practices provides information about how Brooks Eye Center may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
Name of Patient*
Date of Birth*
MM slash DD slash YYYY
I. My Authorization
My authorized person/organization*
I authorize the above person/organization to use or disclose the following health information:*
- All of my health information
- My health information relating to the following treatment or condition
Please write the treatments or conditions
My health information covering the period of healthcare from
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
The above party may disclose this health information to the following recipient:
Name/Organization:*
Phone
Fax
Email
The purpose of this authorization is (check all that apply):*
- At my request
- Second To authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so.
- To authorize the using or disclosing party to sell my health information. I understand that the seller will receive compensation for my health information and will stop any future sales if I revoke this authorization.
- Other
Other
This authorization ends*
- On (Date)
- When I am no longer a patient of the practice
- When the following event occurs
Date
MM slash DD slash YYYY
Event

II. My Rights
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Date*
MM slash DD slash YYYY
Signature of Patient*
If the patient is a minor or unable to sign please complete the following
- Patient is a minor
- Patient is unable to sign because
Years of age
Because
Date*
MM slash DD slash YYYY
Authorized Representative Signature*
Print Name of Representative*
First Last
Authority of representative to sign on behalf of patient:*
- Parent
- Legal Guardian
- Court Order
- Other
Other

III. Additional Consent for Certain Conditions
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.*
- I consent
- I do not consent
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Signature of Patient or Authorized Representative*

IV. Additional Consent for HIV/AIDS
This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.*
- I consent
- I do not consent
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Signature of Patient or Authorized Representative*

V. Notice of Privacy Practices
The signature below indicates that I have been provided with a copy of the Notice of Privacy Practices for the authorized party listed above and have read and understood its content.
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Signature of Patient or Authorized Representative*

Patient Consent Form

Patient Consent Form

Step 1 of 5 - My Authorization

I. My Authorization

My health information covering the period of healthcare from

The above party may disclose this health information to the following recipient:

II. My Rights

III. Additional Consent for Certain Conditions

IV. Additional Consent for HIV/AIDS

V. Notice of Privacy Practices

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