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…

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.

 

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Bloomington/Normal: (309) 829-5311
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Gibson City: (800) 325-7706
Ottawa: (815) 434-4200
Pekin: (309) 347-5115
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Springfield: (217) 529-3937