Hartland Eye Care

Thomas Doud O.D. P.C.

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

I,_____________________________ hereby authorize Thomas R. Doud O.D. P.C. (Hartland Eye Care) to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Hartland Eye Care can refuse to treat me.

I have been informed that Hartland Eye Care has prepared a notice that more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such notices prior to signing this consent.

I understand that I may revoke this consent at any time by notifying Hartland Eye Care in writing, but if I revoke my consent, such revocation will not affect any actions that Hartland Eye Care took before receiving my revocation.

I understand that Hartland Eye Care has reserved the right to change their privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Hartland Eye Care restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that Hartland Eye Care does not have to agree to such restrictions, but that once such restrictions are agreed to, Hartland Eye Care, must adhere to such restrictions.

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Signature of patient or patient's representative Date

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Printed name of patient or patient's representative

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Relationship to patient

I hereby give consent to Hartland Eye Care to leave messages at my home phone number on a machine or with a person regarding appointments, insurance, test results and/or balances.

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Signature of patient Date