Jax Vision Care – Dunn Avenue
I am the patient or the patient's duly authorized representative, and do hereby, voluntarily, consent to and authorize care encompassing all diagnostic and therapeutic treatment regimens necessary in the judgment of my provider, for myself, my minor child, or other. I am aware that the practice of medicine is not an exact science. I acknowledge that no guarantees have been made to me as a result of treatments or performed examinations.
I do, hereby, authorize the release of medical information necessary to file a claim with my insurance company and assign benefits otherwise payable to myself and Jax Vision Care, P.A.
I have been provided the opportunity to read, or have it read to me, the Notice of Privacy Practices at Jax Vision Care, P.A. I understand how information and records may be used and disclosed. I understand that my health record is the physical property of Jax Vision Care, P.A., but the information belongs to me. I have a right to obtain, inspect, and amend a copy of my health record. Any costs associated with this will be my responsibility and must be paid prior. Written requests must be made to the Privacy Officer. I understand that Jax Vision Care, P.A. is required by law to maintain the privacy of my health information. They will require my written authorization to release my information to outside sources with the exception of disclosures for treatment, payment and healthcare operations. These disclosures may include: access to my information by Jax Vision Care, P.A. staff and doctors; billing to me or a third party; in addition, business associates of Jax Vision Care, P.A. Upon the physicians’ best judgment, Jax Vision Care, P.A. may disclose to a family member, relative or close personal friend or any other individual I identify, health information relevant to that person’s involvement in my care. Health information may also be used for research data, organ procurement, marketing, FDA, public health or legal authorities and/or law enforcement authorities. Jax Vision Care, P.A. may call or write me with appointment reminders, cancellations and may leave voice mail messages at home or place of employment as well as on my mobile phone.
I have read and understand ALL of the above policies for Jax Vision Care, P.A. I have been given or will take the opportunity(s) to ask questions or express any concerns. I also attest that any and all information provided by me is true and accurate to the best of my ability.
Patient/Legal Representative Signature: