HIPAA Privacy Authorization Form  

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance  Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**  

1. Authorization I authorize A Proper View OD PLLC to use and disclose my protected health information as described below.  

2. Effective Period  This authorization for release of information covers all past, present, and future periods of healthcare.  

3. Extent of Authorization  I authorize the release of my complete health record (including records relating to mental healthcare,  communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). 
4. This medical information may be used by the person I authorize to receive this information for medical  treatment or consultation, billing or claims payment, or other purposes as I may direct.  

5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a  revocation is not effective to the extent that any person or entity has already acted in reliance on my  authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the  insurer has a legal right to contest a claim.  
6. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned  on whether I sign this authorization.  
7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the  recipient and may no longer be protected by federal or state law.  

Signature of patient or personal representative: 

Optomap Retinal Screening 

Having the overall health of your eyes checked is just as important as having your vision checked! As there are no pain receptors in the retina, most ocular issues have no symptoms until there is a loss of vision. We pride ourselves on giving the most thorough eye exams, and that would not be complete without an internal eye health review! The Optomap retinal screening is a non-invasive scan that becomes part of your medical record to be reviewed and compared yearly. 

This imaging device allows your doctor to detect retinal abnormalities, macular degeneration, glaucoma, as well as other health conditions such as diabetes, high blood pressure, cholesterol, tumors, and other life threatening diseases. 

Our doctor requires having the Optomap retinal screening performed yearly and believes that it is an essential step in managing overall eye health and treatment. In most cases it is considered a non-covered service through insurance and vision policies, and has a small cost of $49.00 which will be collected at the end of your visit.