Our Policies

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations.
I understand that as part of my health care Valley Vision Center originates and maintains paper and/or electronic records describing my health
history, symptoms, exam or test results diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment,
• A means of communication among the many health professionals who contribute to my care,
• A source of information for applying my diagnosis information to my bill,
• A means by which a third-party payer can verify that services billed were actually provided, and
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand Valley Vision Center can provide a Notice of Information Practices with a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent,
• The right to object to the use of my health information for directory purposes, and
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations.

I understand that Valley Vision Center is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulation.

I further understand that Valley Vision Center reserves the right to change their notice and practices and prior to implementation, in accordance with Federal Regulations should Valley Vision Center change their notice to the address I provided (whether U.S. mail or, if I agree, e-mail).