Established Patient Update — Cary Vision Care

Patient Information

Confirm the account we should update.

Patient's full name*

Date of birth

Email address*

Phone number

Information update

Only tell us what's changed since your last visit.

Has your address changed since your last visit?

Has your phone number or email changed since your last visit?

Has your medical insurance changed since your last visit?

Has your routine vision insurance changed since your last visit?

Have your medications changed since your last visit?

Have your allergies changed since your last visit?

Have you had any new health conditions, surgeries, diagnoses, or major health changes since your last visit?

Are you experiencing any new eye problems or vision concerns?

Contact lens update

Do you currently wear contact lenses?

Consent & Signature

Please review Cary Vision Care's Notice of Privacy Practices below. Scroll to read the full notice, then acknowledge that you have reviewed it.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Document version: Notice of Privacy Practices — Effective April 14, 2003

Our commitment to your privacy

Cary Vision Care is committed to protecting the privacy of your personal health information. We are required by law to maintain the privacy of protected health information, provide you with this notice of our legal duties and privacy practices, and abide by the terms of the notice currently in effect.

How we may use and disclose your health information

We may use and disclose your protected health information for treatment, payment, and health care operations. This includes sharing information with other health care providers who are treating you, obtaining payment from your insurance company for services provided, and internal operations such as quality assessment, staff training, and business planning.

Other uses and disclosures

We may use or disclose your health information without your written authorization in limited circumstances required or permitted by law, including public health activities, health oversight, law enforcement, and to avert a serious threat to health or safety. Any other uses or disclosures require your written authorization, which you may revoke at any time in writing.

Your rights

You have the right to inspect and copy your health information maintained by our practice.
You have the right to request corrections to your health information.
You have the right to request an accounting of certain disclosures we have made.
You have the right to request restrictions on how we use or disclose your information.
You have the right to request confidential communications through alternative means or locations.
You have the right to a paper copy of this notice upon request.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Contact

For questions about this notice or to exercise any of your rights, please contact Cary Vision Care directly.

Document version: Notice of Privacy Practices — Effective April 14, 2003

By checking this box, I confirm that I have reviewed Cary Vision Care's Notice of Privacy Practices shown above.By checking this box, I agree that all information provided is accurate to the best of my knowledge.

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