[5235] MGC Optical Solutions Form 2

HIPAA 1, Patient Form 1 and Patient Form 2

Step 1 of 3


HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES


I,
[Please print full legal name here] (the “Patient” or “Patient’s legal representative”), have been presented with the Notice of Privacy Policy of Dr. Ariel Medina, and have been offered a copy of such policy to keep for my records.
I,
[Please initial here] I hereby acknowledge that I have been provided with a copy of the Policy.
[Please initial here] I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may refuse to sign this acknowledgement, Provider may still provide treatment to me.
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MEDICAL DIGITAL VIDEO AND PHOTO CONSENT


I,
[Please print full legal name here] (the “Patient” or “Patient’s legal representative”), understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Dr. Ariel Medina will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies.
I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
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