Optical Academy
All insurances accepted at this location!
You can take advantage of any Optical Academy
Membership discounts for all services too!
Hours:
Who are you registering for:
Myself
Child
PARENT/GUARDIAN DETAILS
Patient Details
The privacy of your medical information is important to us. We understand
that your medical information is personal and we are committed to protecting it. This
notice will tell you about the ways we may use and share medical information about you.
We also describe your rights and certain duties we have regarding the use and disclosure
of medical information. Our Legal Duty-Law Requires Us to keep your medical information
private and give you this notice describing our legal duties, privacy practices, and
your rights regarding your medical information. Notice of Change to Privacy Practices:
Before we make an important change in our privacy practices, we will change this notice
and make the new notice available upon request. Use and Disclosure of Your Medical
Information. The following section describes different ways that we use and disclose
medical information. Not every use or disclosure will be listed. However, we have listed
all of the different ways we are permitted to use and disclose medical information. We
will not use or disclose your medical information for any purpose not listed below,
without your specific written authorization. Any specific written authorization you
provide may be revoked at any time by writing to us. For Treatment: We may use medical
information about you to provide you with medical treatment or services. We may disclose
medical information about you to doctors, nurses, technicians, medical students, or
other people who are taking care of you. We may also share medical information about you
to your other health care providers to assist them in treating you. Notifications: We
may use and disclose medical information to notify or help notify: a family member, your
personal representative or another person responsible for your care. We will share
information about your location, general condition, or death. If you are present, we
will get your permission if possible before we share, or give you the opportunity to
refuse permission. In case of emergency, we will share only the health information that
is directly necessary for your healthcare, according to our professional judgment. We
will also use our professional judgment to make decisions in your best interest about
allowing someone to pick up medicine, medical supplies, x-ray or medical information for
you. Acknowledgement of Receipt and General Consent I acknowledge that I have reviewed a
copy of Optical Academy, Your Eye Exam in Your School. I further consent to the release
of my health information for purposes of treatment, payment and health care operations
and as authorized or required by law under the circumstances described in the Notice of
Privacy Practices. We will send you notifications/reminders of you the event you have
registered
via email and sms. You may receive email updates about Optical Academy. You may
subscribe
anytime by clicking unsubscribe in the email you receive, or responding STOP via sms.
By submitting this electronic form you confirm that you have read this agreement and
agree to its terms and also serves as an acknowledgement that you have received the
HIPPA notice form described above.
