eyeinstituteofwyoming.com - ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
The law requires that The Eye Institute of Wyoming, P.C. make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY
Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you are signing as a personal representative of the patient, please indicate your relationship
Representative
Relationship to Patient
I agree that The Eye Institute of Wyoming, P.C. may disclose certain information of my healthcare to a Personal Representative of my choosing since such person is involved with my healthcare or payments. In that case, The Eye Institute of Wyoming, P.C. will disclose only information that is directly relevant to the person’s involvement with my healthcare or payments.
Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: