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Acknowledgement of Privacy Practices

Acknowledgement of Privacy Practices

  • I understand that in an attempt to protect the privacy of my identifiable health information, Drs. Akel and Favale, P.L. has established a Privacy Policy and guidelines of Privacy Practices within this office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPPA Regulations, a copy of the Privacy Policy & Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.

  • Patient Consent for Use and Disclosure of Protected Health lnformation

  • I hereby give my consent for Drs. Akel and Favale, P.L. to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operatlons (TPO).

    Drs. Akel and Favale, P.L.'s Notice of Privacy Practices provides a more complete description of such uses and disclosures.

    I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Akel and Favale, P.L's reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice may be obtained by forwarding a written request to Drs. Akel and Favale, P.L. Privacy Officer, Anthony Favale at 953 Lane Avenue South, Jacksonville, Florida 32265.

    By signing this form, I am consenting to Drs. Akel and Favale, P.L.'s use and disclosure of my PHI to carry out TPO.

    I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later decline it, Drs. Akel and Favale, P.L., may decline to provide treatment to me.

  • Date Format: MM slash DD slash YYYY

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