AUTHORIZATION TO USE OR DISCLOSE (RELEASE) PERSONAL HEALTH INFORMATION
By signing this authorization, I hereby authorize my health plans, physicians, and pharmacy providers (collectively, my “Providers”) to use and/or disclose my personal health information (“PHI”) to ReVision Optics, Inc. (RVO) and its affiliates to use or disclose (release) my PHI for the purposes of facilitating my treatment with the Raindrop Near Vision Inlay. My authorization applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended, and under the rules and regulations thereunder. For example, PHI that RVO and its affiliates may use or disclose (release) for purposes of this authorization may include:
- Name
- Phone Number
- Age
Should I choose to seek treatment with a RVO affiliate, that affiliate is required by law to protect my PHI. By signing this authorization, I authorize all RVO affiliates to use and/or disclose (release) my PHI for the purpose of facilitating my treatment with Raindrop Near Vision Inlay. I understand that my PHI used or disclosed under this authorization may be re-disclosed by the person(s) or class of person(s) receiving it and may no longer be protected by Federal privacy laws (such as the Privacy Rule). I understand that my health care providers will not condition my medical treatment or payment of treatment on my signing this authorization. I understand that I am entitled to a copy of this authorization. I understand that I may cancel this authorization at any time by mailing a letter requesting such cancellation to info@revisionoptics.com, but that this cancellation will not apply to any information already used or disclosed. The PHI used or disclosed pursuant to this authorization may be re-disclosed as described above. This authorization expires one (1) year from the date signed below. I further understand that I am entitled to a copy of this authorization.
If this authorization is being signed by the patient’s legal representative, you must provide legal documentation authorizing you to act on the patient’s behalf (legal guardianship, power of attorney, personal representative).
