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1. Introduction

Welcome to Mythic Eyewear. We are committed to protecting your health information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This agreement outlines how we collect, use, and protect your personal and health-related information.

2. Acknowledgment of Receipt of Notice of Privacy Practices

By signing this agreement, you acknowledge that you have received and read our Notice of Privacy Practices, which details how we may use and disclose your Protected Health Information (PHI) and how you can access this information.

3. Use and Disclosure of Protected Health Information

We may use or disclose your PHI for the following purposes:

- Treatment: To provide, coordinate, or manage your eye care, including sharing information with your optometrist or ophthalmologist.

- Payment: To obtain payment for the services and products you receive from us.

- Health Care Operations: To support the operation of our business, such as quality assessments, audits, and customer service.

We will only use or disclose your PHI as permitted or required by law.

4. Patient Rights

You have the following rights regarding your PHI:

- Right to Access: You can request a copy of your health information.

- Right to Amend: You can request corrections to your health information if it is inaccurate.

- Right to Restrict Disclosures: You can request restrictions on how we use or disclose your health information.

- Right to Confidential Communications: You can request that we communicate with you through specific means (e.g., email, phone).

- Right to an Accounting of Disclosures: You can request a list of disclosures we have made of your PHI.

5. Security of Your Information

We are committed to maintaining the security of your PHI. We have implemented appropriate physical, administrative, and technical safeguards to protect your information from unauthorized access, use, or disclosure.

6. Authorization for Other Uses

We will obtain your written authorization before using or disclosing your PHI for purposes not described in this agreement or the Notice of Privacy Practices. You may revoke this authorization at any time in writing, except to the extent we have already relied on it.

7. Changes to This Agreement

We may update this agreement from time to time. When significant changes are made, we will notify you and provide the updated agreement for your review. Continued use of our services after such changes constitutes your acknowledgment and acceptance of the new terms.

8. Contact Information

If you have any questions or concerns about this agreement or our use of your PHI, please contact us at:

me@mythiceyewear.com

9. Acknowledgment and Consent

By signing below, you acknowledge that you have read and understood this HIPAA-Compliant Patient Agreement and that you consent to the use of your PHI as described herein.

Patient Name: ___________________________________

Signature: _______________________________________

Date: ___________________________________________