Eye Physicians of Orange County, P.C.

LOCATIONS:  1 HATFIELD LANE GOSHEN, NY / RT 17M MONROE, NY

8 FORESTER AVE. WARWICK, NY /32 CANAL STREET PORT JERVIS, NY

 

 

 Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I have certain rights to privacy regarding my protected health information.  I understand that this information can and will be used to:

 

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by Eye Physicians of Orange County, P.C. of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.  I have been given the right to review such Notice of Privacy Practices prior to signing the consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

 

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations.  I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

1 Hatfield Lane, Suite 3, Goshen (845-294-5128)  ♦  8 Forester Ave., Warwick (845-987-1203)  ♦  845 Rt.17M Monroe, NY (845-782-0129)  ♦  30 Canal St., Port Jervis, NY (845-672-3960)
Eye Physicians of Orange County, PC specialize in General Ophthalmology and Optometry; Medical and Surgical Management of Glaucoma; Pediatric Ophthalmology; Oculoplastics and Cosmetic Surgery; Cataract Evaluation and Surgery; Refractive Surgery; Pre and Post-Operative Care; Evaluation for Glasses and Contact Lenses

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