Patient Forms

HIPAA Privacy Policy & Acknowledgement Form

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HIPAA Privacy Policy

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.

Our Commitment to Your Privacy

At Rohana Optometry, we are dedicated to maintaining the confidentiality and security of your protected health information (PHI). This Notice of Privacy Practices describes how we may use and disclose your medical information and outlines your rights regarding that information.

As required by law, we are committed to:

• Maintaining the privacy and security of your PHI.
• Providing you with this notice that explains our legal duties and privacy practices.
• Abiding by the terms outlined in this notice for all PHI we maintain.

How We May Use and Disclose Your PHI

We may use or disclose your PHI for the following purposes without your written consent:

1. Treatment – to provide, coordinate, or manage your vision care.
2. Payment – to share with your insurance company or third-party payer for billing and claims.
3. Health Care Operations – for staff training, audits, accreditation, and customer service activities.

Other Permitted Uses and Disclosures

By law, we are allowed or required to share your health information without your permission in situations such as:

• Public health and safety reporting
• Audits or reviews by health agencies
• Court orders or legal requests
• Law enforcement when necessary
• Workers’ compensation or job-related injuries
• To protect someone from a serious health or safety threat

Acknowledgement Form

Please read the following information carefully and confirm your understanding and agreement by signing below.

1. HIPAA Privacy Practices And Office Policy

I acknowledge that I have received the HIPAA Practice Policy and Office Policy. These documents describe how my protected health information may be used and disclosed by this practice. They also include information about co-pay charges and other important office policies.

2. Insurance and Billing Policy

I understand that the office makes its best effort to estimate my insurance coverage and financial responsibility at the time of my visit. However, this estimate is not final until the office receives the Explanation of Benefits (EOB) from my insurance company. I understand that I am responsible for any balance not covered by insurance.

3. Patient Portal Access

I understand that this office uses a secure Patient Portal, which is automatically activated following my first visit. My login information will be emailed to me before I leave today. Through this portal, I can access:

• My medical records
• Glasses prescriptions
• Contact lens prescriptions (if applicable)

I agree to check that I’ve received the email before leaving. If I choose not to provide an email address, I understand that I will not have access to the portal.

Acknowledgement and Signature
By signing below, I confirm that I have read and understand the above statements regarding HIPAA Privacy, insurance responsibility, and the patient portal.

👉 Please draw your signature below using your mouse or finger: