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.

Patient Name(Required)

First Last

Date of Birth(Required)

Please select

I have read, understand and acknowledge the Privacy Policy and Practices at Anderson Eyecare
I have elected not to read the Privacy Policy and Practices at Anderson Eyecare
A copy of the Anderson Eyecare Privacy Policy and Practices was given to me today

I hereby authorize the following person(s) to have access to my financial and medical records.(Required)

You may add up to three people.

Name	Relationship

Signature(Required)

Date signed(Required)

Phone

This field is for validation purposes and should be left unchanged.

Monday	8:00am	6:00pm
Tuesday	9:00am	6:00pm
Wednesday	Closed
Thursday	8:00am	6:00pm
Friday	7:00am	5:00pm
Saturday	Closed
Sunday	Closed

Acknowledgement of Privacy Policies and Practices Form

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