I, hereby provide my consent to Laser Eye Surgery of Erie, Inc. for the use of my protected health information (PHI) to facilitate the refill of my medication. I acknowledge that this PHI may include my name, date of birth, prescription details, and contact information. Furthermore, I understand that I have the option to opt out of these medication refills at any time by contacting Laser Eye Surgery of Erie, Inc. I am aware that my PHI will be handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This assures me that my PHI will remain confidential and will exclusively be utilized for the purpose of refilling my medication. I have thoroughly read and comprehended the above privacy and HIPAA consent statement. By checking the box, I confirm my consent.