Notice of Privacy Practices and Patient Consent For Use and Disclosure of Protected Health Information

If you would prefer to download a PDF version of this form and return to the office, please click here.

I understand…

• That under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected
  health information.
• That Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur may use or disclose my protected health information for treatment, payment or health care operations – which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information
  without my authorization.
• Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.
• That I have the right to read the ‘Notice’ before signing this agreement. If I ask, Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur will provide me with the most current Notice of Privacy Practices.
• Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur’s policy is to call patients by their first and last names.

My electronic consent below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur to use and disclose my protected health information to carry out treatment, payment, and health care operations, including release of medical information to my insurance/Medicare carrier to determine benefits payable for related services. I understand that I am financially responsible to the clinic for any charges covered by this authorization. Some routine eye‐care costs (i.e. refractions) are generally not covered by insurance/Medicare. I understand that these costs are my responsibility. In the event collection efforts become necessary I agree to pay all reasonable collections costs up to 40% of the amount owed, plus reasonable attorney fees and court costs. I have the right to revoke this consent in writing at any time, except to the extent that Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur has taken action relying on this consent.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any time by contacting: Gailey Eye Clinic, LTD., 1008 N. Main St., Bloomington, IL 61701 800-325-7706.