Family Vision Center of Crosby HIPAA

DATE:*

The undersigned acknowledges they can receive a copy of the currently effective Notice of Privacy Practices for this healthcare facility upon request. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please Enter First and Last Name of the Patient*

First Last

Please Sign for Patient/Guardian of Patient*

Your comments regarding Acknowledgements or Consents

How do you want to be addressed when summoned from the reception area?*

Please list any parties who can have access to your health information.

First Last Relationship

Please list any parties who can have access to your health information.

First Last Relationship

I authorize contact from this office to confirm my appointments, treatment & billing information via:*

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to My Cell Phone
Email Confirmation
Any of the Above

Cell Phone Number

Home Phone Number

Email Address

Work Phone Number

I authorize information about my health be conveyed via:

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to My Cell Phone
Email Confirmation
Any of the Above

I approve being contacted about special services, events, fund raising efforts or new health info on behalf of this Healthcare Facility via:

Phone Message
Text Message
Email
Any of the Above
None of the Above (Opt Out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.