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 Used or Disclosed
For eyewear production and fulfillment:
- Face scan data
- Eye examination and prescription information
- Information necessary for the production and fitting of eyewear
For insurance-related purposes:
- Eye examination and prescription information, where applicable
- Date of birth
- Insurance information
- Billing and purchase information
3D face scan data is not disclosed to insurance providers.
III. Purpose of the Use or Disclosure
The information described above may be used or disclosed as necessary to provide eyewear-related services, including eyewear design, production, fitting, order fulfillment, and billing.
Certain information may also be disclosed to insurance providers as necessary to process insurance-related documentation or reimbursement. 3D face scan data is not disclosed to insurance providers.
IV. Persons/Organizations to Whom Information May Be Disclosed
| Recipient | Information that may be disclosed | Purpose |
|---|---|---|
| Coptiq Co., Ltd. (Breezm Headquarters, South Korea) | 3D face scan data, prescription information, and other information necessary to fulfill the order | Eyewear design, production, fitting, and order fulfillment |
| Insurance Providers | Name, date of birth, contact information, insurance information, purchase and billing information, and prescription information where necessary | Processing insurance-related documentation or reimbursement |
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.
