Bay Area Eye Center Form – Bay Area Eye Center Pearland

Bay Area Eye Center Bruce Cline OD Shannon LeBus OD

Patient Disclosure Instructions

In general, the HIPAA privacy rule gives individuals the right to request a restriction
on uses and disclosures of their protected health information (PHI). The individual is
also provided the right to request confidential communications or that a communication
of PHI be made by alternative means, such as sending correspondence
to the individual's office instead of the individual's home.

Patien Name

Date of Birth

I wish to be contacted in the following manner (check all that apply)

Cell phone

Written CommunicationOK to leave message with detailed informationOK to mail to my home AddressLeave message with call-back number only

Home phone

OK to leave message with detailed informationLeave message with call-back number only

Work phone

OK to leave message with detailed informationLeave message with call-back number only

I allow Bay Area Eye Center to give my clinical information to or answer question from (check all apply)

[recaptcha]