Dr. Kurtbay Optometry
750 Irving Street
San Francisco, CA 94122
(Phone) 415-759-5448
(Fax) 415-759-9399
CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT,
PAYMENT AND HEALTH CARE OPERATIONS
In the course of providing service to you, we create, receive, and store health information that identifies you. It
is often necessary to use and disclose this health information in order to treat you, to obtain payment for our
services, and to conduct health care operations involving our office.
We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You
are free to refer to this notice at any time before you sign this consent document. As described in our Notice of
Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes
care and services provided here, but also disclosures of your health information as may be necessary or
appropriate for you to receive follow - up care from another health care professional. Similarly, the use and
disclosure of your health information for purposes of payment includes submission of your health information
to third - party payers or insurers for claims review, determination of benefits and payment; our submission of
your health information to auditors hired by third - party payers and insurers, among other aspects of payment
described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our
privacy practices change. You can get an updated copy here at our office.
When you sign this consent document, you signify that you authorize us to use and disclose your health
information to treat you, to obtain payment for our services, and to perform health care operations. You can
revoke this consent in writing at any time, unless we have already treated you, sought payment for our services,
or performed health care operations in reliance upon our ability to use or disclose your health information in
accordance with this consent. We can decline to serve you if you elect not to sign this consent form.
You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health
care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these
suggested restrictions. If we do agree, the restrictions are binding to us. Our Notice of Privacy Practices
describes how to as for a restriction.
I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE
OF MY HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH
CARE OPERATIONS.
