Patient Consent

  • By signing this form, you consent to our use and disclosure of Protected health information about you for treatment, payment, and Health care operations. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996(HIPAA) Privacy policies available upon request.

    I give my permission for Virginia Eye Consultants to discuss my Personal health information with the following people:

  • Print Name
  • Relationship
  • Print Name
  • Relationship
  • Print Name
  • Relationship
  • Print Name
  • Relationship
  • Patient Name/Electronic Signature*
  • Date * (mm/dd/yyyy)