HIPAA Consent Form

I acknowledge that I have been given the opportunity to receive a copy of this optometrist practice's HIPPA Notice of Privacy Practices.*
- Accept and Receive
- Decline to Receive
I hereby authorize the following persons to receive information of my health records and/or account information:
signed by*
- Patient
- authorized authority representative
Patient Name(Please Print)*
First Last
Patient Signature*
Date*
MM slash DD slash YYYY
Authority of Representative to Sign for Patient: (check)
- Parent
- Guardian
- Power of Attorney
- Other
Name of Personal Representative*
First Last
Signature of Personal Representative*
Date*
MM slash DD slash YYYY
Please Note: It is your right to refuse to sign this Acknowledgement.
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