Optometric Physician Brighton Eye Care

Dr. Sergio H. Peneiras

Optometric Physician Brighton Eye Care Excellence in Eye Care 112 Brighton Avenue Long Branch, N. J. 07740 Tel: 732-870-1088

Notice of Privacy Practices

Please print patient name ______

We are required by law to maintain the privacy of, and provide individuals with a notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please speak with our HIPAA Compliance Officer in person or by phone at our main phone number listed above. I have been given the opportunity to read, and if desired, take home the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. _X_ YES ___ NO I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. _X_ YES ___ NO I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon prior consent. If I do not sign this consent, or later revoke it, Advanced EYE Professionals, LLC may decline to provide treatment to me.

Signature of Patient or Legal Guardian ______Date ______

Dilation Often Eye exams require eye drops in order to dilate your eyes. This may cause blurry vision for several hours. We recommend that you bring sunglasses or we will provide them for you. It is also recommended that you have someone else drive. I have read understand the Dilation statements. I also acknowledge that I have been given the opportunity to receive a copy of this form.

Signature______Date ______

Referral If your insurance requires a referral, it is your responsibility to obtain the referral for your appointment. If not, you will be billed for the visit.

Signature______Date______

Release of Medical Information In the event that for any reason I am difficult to reach, my test results, other medical information regarding my condition, appointments, insurance, or any other pertinent medical information may be released to: Name ______Phone ______Relationship ______Name ______Phone ______Relationship ______Name ______Phone ______Relationship ______

X ______X ______Print Name of Patient or Legal Guardian Signature of Patient or Legal Guardian Date ______