Acknowledgement of Privacy Policies and Practices Form

  • I understand that in an attempt to protect the privacy of my Personal Identifiable Health Information (also known as PHI), Anderson Eyecare has established a Privacy Policy and guidelines for Privacy Practice within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purposes of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Anderson Eyecare Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy; one will be given to me at no charge.
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