HIPAA Consent Form HIPPA 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.CAPTCHA
