Healthcare Vision Document

HEALTHCARE VISION DOCUMENT

Patient Name:   Date of Birth:   Gender: Male Female Other

Patient Information

Insurance Information

Vision Medical History

Proposed Examination / Treatment Plan and Consent

Procedure / Service to be provided:

The practitioner has explained the nature and purpose of the above procedure, the anticipated benefits, the material risks and potential complications (including, where applicable, visual acuity changes, infection, inflammation, need for additional procedures) and reasonable alternatives including no treatment. I have had the opportunity to ask questions and they have been answered to my satisfaction.

I acknowledge receipt of an explanation of risks, benefits, and alternatives, and I consent to the proposed examination and treatment plan:

I understand that I may refuse or withdraw consent at any time prior to the procedure without affecting my right to future care or treatment. Withdrawal of consent will be provided in writing, except in emergency circumstances where refusal would jeopardize my health.

Authorization for Use and Disclosure of Protected Health Information (PHI)

I authorize the release and disclosure of my vision-related protected health information as reasonably necessary to carry out treatment, payment, and health care operations. I authorize release of medical records to insurers, referring providers, and other health care professionals involved in my care. I understand that the information released may include diagnosis, treatment notes, test results, and billing information.

I understand that I may revoke this authorization at any time by delivering a written revocation to the facility, except to the extent that action has already been taken in reliance on this authorization. This authorization is voluntary and not a condition of treatment except where treatment is solely for the purpose of creating protected health information for disclosure to a third party.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered the facility's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights with respect to that information.

Permission to leave appointment reminders, test results, or treatment information via voicemail or text message: Voicemail Text Message

Patient Certification and Statements

By signing below I certify that the information I have provided is accurate and complete to the best of my knowledge. I have had the opportunity to ask questions, and I understand the explanations provided. I authorize the practitioner and staff to perform the agreed evaluation and treatment.

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