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Insurance Signature Form

  • Urban Eyes, Inc. HIPAA Patient Record of Disclosures

  • In general. the Health Insurance Portability and Accountability Act (HIPAA) 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 communication or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of home.

    The privacy rule requires that healthcare providers take reasonable steps to insure that your privacy is protected. Urban Eyes, Inc. is HIPAA compliant and will not disclose any private information unless specifically needed and approved by the patient.

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