HIPAA Authorization Release Form (required) 

Coptiq Inc (d/b/a Breezm Eyewear)
526 Seventh Ave. 8th Fl. New York NY 10018
(716) 300 2020
contact@breezm.com 

Authorization to Use or Disclose Protected Health Information (PHI)
Under HIPAA (Health Insurance Portability and Accountability Act) 

I. Authorization  
I hereby authorize Coptiq Inc and its designated staff to use and disclose the specified health information, including but not limited to my health information pertinent to the provision and fitting of eyeglasses, as detailed below. 

II. Type of Information to be Disclosed
Face scan data
Eye examination and prescription information
Date of birth
Diagnosis information related to eyecare
Insurance information
Billing and appointment information

III. Purpose of the Use or Disclosure
The purpose of this disclosure is to ensure proper selection of eyeglasses, fitting, and billing of eyeglasses.
This may also include the sharing of necessary information with third-party insurance companies,
as required for the processing of orders, insurance claims, or continuity of care. 

IV. Persons/Organizations to Whom Information May Be Disclosed
Eyeglass Frame and Lens Suppliers (Coptiq Co., Ltd — the headquarters of Coptiq Inc)
Insurance Providers 

V. Right to Review
I understand that I have the right to review my records in writing which Coptiq Inc may charge for the service. My signature on this form indicates that Coptiq Inc has the right to phone, email, or send a text message to me to confirm appointments and/or discuss my medical conditions  

VI. Right to Revoke
I understand that I have the right to revoke this authorization at any time by submitting a written request to Coptiq Inc. I understand that the revocation will not apply to information that has already been released in response to this authorization.

VII. Expiration

This authorization will remain in effect until I withdraw it in writing. 

VIII. Signature

I understand that I have the right to refuse to sign this authorization and that Coptiq Inc has the right to refuse to provide me with its services. I have read and understand the terms of this authorization and I hereby provide my consent freely and voluntarily. Coptiq Inc. respects your privacy and is committed to treating and using your protected health information responsibly. This authorization complies with the HIPAA Privacy Rule.