Welcome! Thank you for trusting us with your eye health care. We promise to do our best to provide you with the finest care available.
PATIENT REGISTRATION
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WE ACCEPT INSURANCE ASSIGNMENT
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655 Medical Center Dr NE         |         Salem, Oregon 97301         |         503.581.5287         |       Fax 503.588.6843       |       mceyeclinic.com






MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.

ACKNOWLEDGE AND CONSENT


PATIENT NAME (PLEASE PRINT)
PARENT / GUARDIAN (PLEASE PRINT)

I understand that my ophthalmologist will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health, history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions and similar types of health–related information.

I understand and agree that the independent physicians and surgeons located at Medical Center Eye Clinic may use and disclose my health information in order to:

I also understand that I have the right to receive and review a written description of how my ophthalmologist will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees and independent physicians and surgeons, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of a summary of the most current version of Medical Center Eye Clinic’s Notice of Privacy Practices in effect will be posted in the reception area and available on the Website at mceyeclinic.com. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that physicians located at Medical Center Eye Clinic are not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.

BY SIGNING BELOW, I AGREE THAT I HAVE REVIEWED AND UNDERSTAND THE INFORMATION ABOVE AND THAT I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES.

Date
SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE



655 Medical Center Dr NE         |         Salem, Oregon 97301         |         503.581.5287         |       Fax 503.588.6843       |       mceyeclinic.com