Due to new regulations mandated at both the state and federal level, we are now obligated to collect the
race, ethnic background and preferred language of each patient. This information will go into your medical
record and remains strictly confidential.
I hereby consent to a health examination, related diagnostic procedures and treatments provided by the Eye
Center. I hereby authorize my insurance company(s) to remit directly to the Eye Center all payment of
benefits otherwise payable to me under the provision of my policy(s). I request that payment of authorized
Medicare/Medicaid benefits be made either to me or on my behalf to the Eye Center for any services
provided to me. I hereby authorize the release of this information needed to determine benefits payable for
related services. I also authorize the use of any photographs or data collections taken to document my ocular
condition for routine care or use in research and professional publication. Photo static copies of this
authorization will be considered valid as the original.
If my insurance company requires referrals, vouchers or authorizations, I will present these to the
receptionist immediately. Failure to do so will make me responsible for full payment once services are
4. History of the following diseases: (please check all that apply)
Authorization of Use and Disclosure of Protected Health Information for Individuals
Persons Authorized to Receive Information:
Health information Optomedica Eye Consultants, LLC collects or received about you may
be disclosed to the following persons:
Use and Disclosure of Information:
I authorize the person(s) listed above to receive all health information about appointments, treatment
and/or other information pertinent to my healthcare and/or payment for my health care provided at
Optomedica Eye Consultants, LLC .
Expiration Date of Authorization
This authorization is effective through
unless revoked or terminated by the
patient or patient’s personal representative.
Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to
Optomedica Eye Consultants, LLC/Caplan Surgery Center. You should contact our Privacy Officer to terminate this
Potential to Re-disclosure
The person to whom health information is sent may repeatedly disclose health information that is
identified by this authorization. The privacy of this information may not be protected under the
federal privacy regulations